
Pass Tf\ " R S" 

Book / & 



Copyright N?.. 



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COPYRIGHT DEPOSIT. 



1 

BOOKS 

BY 

GEORGE P. PAUL, M. D. 



Nursing in Acute Infectious Fevers 
i2mo of 246 pages, illustrated. 

Cloth, $I.OO net. Second Edition 



Materia Medica for Nurses 

i2mo of 280 pages. Cloth, 
$ 1 . 5 o n et. Second Edition 



NURSING 

IN THE 

ACUTE INFECTIOUS 
FEVERS 



BY 
GEORGE P. PAUL, M.D. 



TOWN HEALTH OFFICER, ROUND LAKE, NEW YORK ; SOMETIME VISITING 
PHYSICIAN TO THE SAMARITAN HOSPITAL AT TROY, NEW YORK 



I llus trat ed 



SECOND EDITION, THOROUGHLY REVISED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1911 






Copyright, 1906, by W. B. Saunders Company. Reprinted August, 1906, 

and November, 1909. Revised, reprinted, and 

recopyrighted April, 191 1 



Copyright, 1911, by W. B. Saunders Company 



PRINTED IN AMERICA 

PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 






2)CLA289820 



PREFACE TO SECOND EDITION 



In response to the demand, this book has been 
thoroughly revised. Much new material has been 
inserted, several chapters rewritten, new articles on 
Acute Anterior Poliomyelitis and Paratyphoid Fever 
added, and important additions and revisions made 
in the chapters on Reduction of Fever, Alleviation of 
Symptoms. Detection of Complications, Urine and its 
Examination, and Poisons and their Antidotes. 

It is hoped this edition will meet with as hearty 
welcome as its predecessor, and that it will prove as 
useful, if not more so, not only to the nursing, but 
also the medical profession. 

G. P. P. 

Round Lake, N. Y. 
April, 191 1. 



PREFACE 



The object of the author in preparing this book is to 
place before the nursing profession a volume which 
will be of practical service. 

The subject-matter is written for the nurse, and not 
the medical graduate or scientific worker, hence all 
extraneous matter and useless discussions are not 
given place. 

The treatment of disease by means of drugs and 
the physical signs are but little discussed, as these are 
of more importance to the medical attendant than to 
the nurse. 

Great pains have been taken in preparing the sec- 
tions on the Care and Management of each disease, 
as this relates directly to the duties of the nurse. 

The book is divided into three parts : The first part 
treats of fever in its general aspects, which is necessary 
as a base to the study of each individual fever ; the 
second part discusses each of the acute infectious 
fevers as to their cause, signs and symptoms, course, 
prognosis, care, and management ; the third part deals 
with practical procedures and information necessary 
in the management of the foregoing diseases or of 
value in understanding the nature and course of such 
diseases. 

7 



8 PREFACE 

Only illustrations and charts of a specific value are 
included. 

The author wishes to express his thanks to Susan 
D. Munroe, Assistant Superintendent, Samaritan Hos- 
pital, for her kind and candid criticism. 

G. P. P. 



CONTENTS 
PART I.— GENERAL CONSIDERATIONS 



CHAPTER I 

PAGE 

Fever in General 13 

CHAPTER II 

Hygiene of the Sick Room 21 

CHAPTER III 

Diet of the Sick 28 

CHAPTER IV 

Reduction of Fever 40 

CHAPTER V 

Alleviation of Symptoms „ 48 

CHAPTER VI 
Detection of Complications 62 



PART II.— SPECIAL DISEASES 

CHAPTER VII 

Typhoid Fever and Paratyphoid Fever 71 

CHAPTER VIII 

Smallpox 95 

9 



IO CONTENTS 

CHAPTER IX 

PAGE 

Scarlet Fever 103 

CHAPTER X 

Measles 114 

CHAPTER XI 

German Measles 119 

CHAPTER XII 
Mumps 122 

CHAPTER XIII 
Whooping-cough 1 24 

CHAPTER XIV 
Influenza 129 

CHAPTER XV 

Epidemic Cerebrospinal Meningitis 134 

CHAPTER XVI 
Acute Epidemic Anterior Poliomyelitis 138 

CHAPTER XVII 
Lobar Pneumonia 148 

CHAPTER XVIII 

Diphtheria 157 

CHAPTER XIX 

Acute Articular Rheumatism 168 

CHAPTER XX 
Malarial Fever 174 

CHAPTER XXI 
Erysipelas 182 



CONTENTS II 

CHAPTER XXII 

PAGE 

Septicemia, Toxemia, and Pyemia 187 

PART III.— ADDENDA 

CHAPTER XXIII 
Antitoxins and Bacterial Vaccines 193 

CHAPTER XXIV 
Bacteria 199 

CHAPTER XXV 

Urine and its Examination 204 

CHAPTER XXVI 

Signs of the Onset of the Toxic Effects of Drugs .... 213 

CHAPTER XXVII 
Poisons and Their Antidotes 215 

CHAPTER XXVIII 

Enemata and Topical Applications 219 

CHAPTER XXIX 

Antiseptics and Disinfection 222 

CHAPTER XXX 

Abbreviations, Weights and Measures 232 

CHAPTER XXXI 

Miscellaneous Notes 235 

Index . . . . 237 



PART L 

GENERAL CONSIDERATIONS. 

CHAPTER I. 

FEVER IN GENERAL. 

Fever is that condition of the human body in which 
the temperature is raised above the normal. 

The normal human body temperature is 98.6° F., 
but it may vary a little either way, depending upon 
several conditions. 

Physiologically, the temperature of a healthy adult 
is at its lowest between midnight and four o'clock in 
the morning. It is at this time, when the body func- 
tions are at their lowest, that patients ill with grave 
diseases are most likely to pass away. The tempera- 
ture reaches its height between five and eight o'clock 
P. M., and then gradually decreases until early morn- 
ing. In persons who toil at night instead of day this 
ratio may become reversed and the height is reached 
in the morning. 

The normal temperature is lowered in several ways ; 
insufficient diet may lower the temperature a fraction 
of a degree. In starvation the temperature may become 
very subnormal. In certain febrile diseases, either be- 
cause insufficient nourishment is provided or because 
the patient swallows but little food, a subnormal tem- 

13 



14 FEVER NURSING. 

perature may result, especially in the beginning of 
convalescence. One of my cases of typhoid fever at 
the beginning of convalescence had attacks in which 
he would enter a state of collapse, the temperature 
would become subnormal, the skin pale and moist, but 
the pulse would remain normal. By careful watching 
we learned that he would hold the milk in his mouth 
until the nurse turned her back or left the room, when 
he would expel it. This he kept up for a week or 
more, probably getting only a fraction of a glassful 
of milk in twenty-four hours. 

Cold drinks lower the temperature temporarily ; 
cold baths lower the normal temperature. After tak- 
ing an anaesthetic the temperature is also lower than 
before ; and certain drugs, such as morphine, quinine, 
large doses of alcohol, coal-tar preparations, as ace- 
tanilid, antipyrin, phenacetin, etc., will lower the bodily 
heat. During sleep the temperature is lower than in 
the wakeful hours. 

The normal temperature is raised after partaking of 
a liberal diet, or hot drinks ; during digestion ; by in- 
creased function of the large glands of the body ; by 
increased mental activity and muscular exertion. In 
summer the bodily temperature is a little higher than 
in winter. Such drugs as strychnine, atropine and caf- 
feine will raise the temperature. This is a verv im- 
portant point, because the continued rise of tempera- 
ture in the convalescence of certain diseases, as ty- 
phoid fever, may be due to the administration of 
strychnine. 

Degrees of Temperature. — The normal tempera- 
ture is 98.6 F. or 37 C. The normal temperature 
of an infant is about 99.4 F. and decreasing gradually 






FEVER IN GENERAL. 15 

to the normal adult temperature as full growth is 
obtained. After the age of 40 or 50 years the tem- 
perature decreases to about 97.8 ° F. and in advanced 
age rises again to 99.4 ° F. Thus in both extremes of 
life the temperature is about the same and is above 
normal. 

95 F. equals Collapse temperature. 

97.5 ° F. equals Subnormal temperature. 

98.6 F. equals Normal temperature. 

99.5°-ioi.5° F. equals Sub febrile temperature. 

I02°-I03° F. equals Moderately febrile temperature. 

I04°-I05° F. equals Highly febrile temperature. 

Over 106 F. equals Hyperpyretic temperature. 

Detection of Temperature. — This is done by 
means of the clinical thermometer, the bulb of which 
is placed under the tongue and the lips closed, the 
patient being warned not to bite the instrument. The 
thermometer is left in position from one to five min- 
utes, depending on the grade and sensitiveness of the 
instrument. As a general rule the temperature is 
taken by the mouth, but at certain times this is either 
not possible or desirable. For example, it is impos- 
sible to take the temperature in young children by 
mouth; in adults who are in a comatose or semi- 
comatose condition ; and in insane patients. If the 
tongue be dry, the recorded temperature will not be 
accurate, nor if the patient had recently drunk cold 
or hot water. Other situations for taking the tem- 
perature are in the axilla, in the rectum, in the vagina, 
and in the passing urine. 

Before placing the thermometer in the axilla, the 
armpit should be thoroughly wiped and dried. The 
bulb of the thermometer is then put well into the cen- 



1 6 FEVER NURSING. 

ter of the axilla, and the hand of that side placed on 
the front of the chest so as to completely envelop the 
bulb of the thermometer with the axillary tissues. The 
instrument should be allowed to remain in position 
for five minutes. To the recorded temperature add 
about 0.5 ° F., which will bring it up to the oral tem- 
perature. 

The instrument may also be placed in the rectum or 
vagina. It is very seldom necessary to use this method 
except in children, or in adults who are unconscious, 
delirious, or insane. If used rectally, the rectum should 
first be emptied of fecal matter, for if the bulb of the 
thermometer be inserted into a mass of feces, an in- 
correct reading is obtained. The rectal temperature, 
when properly taken, is a true index of the degree of 
body heat. 

Another method is by allowing the patient to urin- 
ate on the bulb of the thermometer. This is an accu- 
rate method, but applicable to only a few cases. 

In febrile diseases it is best to record the tempera- 
ture every four hours during" the, acute stage of the 
disease. 

Prognosis. — The prognosis of febrile diseases does 
not entirely depend on the fever, but also on the con- 
comitant symptoms. A fever of 106 F. for a brief 
period is not as grave as one of 105 ° F. for a more 
extended time. An evening temperature of 104 F. 
in typhoid fever is of more import than a fever of 
105 ° F. in pneumonia. 

A temperature of 106 F. if continued for several 
days is fatal (Smith). In persons over 50 years of 
age a temperature of 103° F. is serious. 

The relation of the pulse is very important in mak- 



FEVER IN GENERAL. 1 7 

ing a prognosis. If the evening temperature does not 
rise above 104 F. and the pulse is good, the prognosis 
is favorable. In diphtheria a temperature of 101 F. 
and a pulse of 120 is grave. If the temperature con- 
tinue at 105 ° F. for four or five hours in a case of 
typhoid fever, the prognosis is grave. 

Children tolerate a higher fever than adults. A 
temperature of 104 F. in a child is of the same import 
as 102 F. in an adult. Disproportion between the 
surface and mouth temperature is serious. 

Sudden and continuous rise of temperature in the 
course of a disease, if all complications can be ex- 
cluded, is usually antemortem. 

Stages of Fever. — Fever may be divided into 
three stages ; namely, invasion, fastigium, and decline. 

Invasion extends from the beginning of the febrile 
manifestations until the fever reaches its height. It 
varies in length, degree, and character in various dis- 
eases. In typhoid fever the invasion is of about ten 
days' duration. The fever gradually increases in a 
step-like manner, with diurnal remissions for seven 
to ten days, when it reaches its height. In pneu- 
monia, on the other hand, the invasion is very abrupt 
and of short duration. The fever reaches its height, 
as a rule, in twenty-four or forty-eight hours. 

Fastigium is that period when the fever is at its 
height, and extends from the end of the invasion to 
the beginning of decline. In typhoid fever the fastig- 
ium is about twelve days long. The evening rise 
reaches about the same height every day and the diur- 
nal remission is less than the remission during the 
invasion. In pneumonia the period of the fastigium 
2 



1 8 FEVER NURSING. 

is shorter than in typhoid, lasting as a rule, from four 
to six days, with hardly any remission. 

Decline of fever may take place in one of two ways: 
by lysis, that is, a gradual fall of the fever ; or by 
crisis — a sudden fall to normal. The principal diseases 
in which the temperature falls by crisis are lobar pneu- 
monia, typhus fever, erysipelas, measles, relapsing 
fever, and influenza. In most other diseases the fall 
is by lysis. 

Types of Fever. — All fevers may be placed under 
three heads : continued, remittent, intermittent. In 
continued fever the temperature remains at a more or 
less constant height, with little or no daily remission. 
Examples of this type are lobar pneumonia and typhoid 
fever. In remittent fever, the diurnal remission is 
marked, but the lowest daily temperature is still above 
the normal, as in malarial remittent fever and in 
certain types of tuberculosis. In intermittent fever the 
temperature falls to the normal or subnormal diurnally 
and again rises, as in malarial intermittent fever, re- 
lapsing fever, and certain forms of tuberculosis. 

Phenomena of Fever. — Rise of temperature may 
be the result or the cause of other concomitant symp- 
toms. Among the common accompaniments of fever 
are headache, malaise, muscular pains, languor, chilly 
sensations, loss of appetite, coated tongue, tendency 
to yawn, flushed face, glistening eyes, nausea or vom- 
iting, constipation as a rule, increased rate of pulse 
and respirations, hot and dry skin. The urine is con- 
centrated, small in amount, dark in color, of high 
specific gravity and contains albumin. 

Treatment of Fever. — There are eight divisions 
to the proper treatment of fever; namely, neutralize 



FEVER IN GENERAL. 



19 



the poison ; promote elimination ; reduce the tempera- 
ture if high; maintain nutrition; stimulate when neces- 



m 










































ME 


MJE 


M 


E 


M 


E 


mIe 


ME 


M 


E 


ME 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 




108 
107 


































































108 
10? 
106 

105 
104- 

103 
102 
101 
100 
99 
98 
97 


106 








































































104 

ICi 


























































101 






























































IQo|zz^tJ 






































































98 
97 




















=p 










































jJ5 







Fig. 1. — Temperature chart of a continued fever. 

sary; relieve symptoms; prevent and counteract com- 
plications ; use care in convalescence. 



MTf 








































108 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


ME 


M 


E 


M 


E 


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E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


108 


10/ 
106 
105 
104 
103 
102 
101 
100 
99 

9e 

97 








































































107 

106 
105 
104 


















































1 




| 
















103 
102 
101 
100 
99 
96 
97 





































































Fig. 2. — Temperature chart of a remittent fever. 

Neutralise poisons. — This is very difficult. In those 
diseases for which we have antitoxins they should be 



20 



FEVER NURSING. 



used early and in sufficient quantity. Hypodermocly- 
sis of normal saline solution is very useful in diluting 



Dai 
















(03 


4 8 12 4 8 12 


4 a 


12 4 


a 


12 


4 8 


12 


4- 


6 


12 


4 


8 12 


4 6 12 


4 


8 12 4- 


8 


12 


4- 8 


12 4 


8 12 


108 


107 

106 

105 
104 

103 












































107 
106 
105 

104 

103 


101 
100 
99 
93 
97 














































101 

100 
99 
93 
97 


'•} ~ T 


•■I i t- 




















_ 1 










=(= p | 1 i 


I 














11 











Fig. 3. — Temperature chart of an intermittent fever. 

the poisons in the blood and aiding in their elimination. 
In those diseases in which toxins are formed in the 
intestinal tract, certain disinfectants as salol, creosote, 
guaiacol, and thymol are useful. 

Promote elimination by the bowels with purgatives 
and enemata. By the kidneys in giving plenty of 
water to drink ; also rectal infusions and hypoder- 
moclyses of normal saline solution. By the skin with 
hot packs, hot dry air, and hot drinks. 

Reduce the temperature by hydrotherapeutic meas- 
ures (see subsequent articles) and by means of drugs. 

Maintain nutrition by food of proper quality and in 
proper quantity. 

Stimulation and other headings under general treat- 
ment will be considered in subsequent chapters. 



CHAPTER II. 

HYGIENE OF THE SICK ROOM. 

Ventilation. — One of the most important consid- 
erations of the sick room is its ventilation. The refuse 
or altered products of all substances taken into the 
body for its nourishment are eliminated as worthless 
to the human economy and are not to be introduced 
into the system. This is just as true in regard to the 
respiratory system. Air rich in oxygen is inhaledj 
the oxygen is used to maintain the vital processes, 
and a combustion product, known as carbon dioxid, 
and certain organic materials worthless to the human 
being, are exhaled, and are not supposed to return to 
the body. This makes it necessary to provide a free 
exit for these substances from the breathing area of 
the person. 

The oxygen of the inhaled air combines with cer- 
tain elements of the blood and displaces the carbon 
dioxid of the blood. This latter has been carried by 
the circulation from the different parts of the body 
to the lungs, and is eliminated in the expired air, to- 
gether with a small amount of organic material. 

If a person be confined in a closed room, he will in 
a certain time, depending on the size of the room, 
have used all the available oxygen of the air and have 
replaced it with carbon dioxid and organic matter. 

21 



22 FEVER NURSING. 

These will begin to act as poisons and destroy the life 
of the person unless he be taken out of the room, or 
fresh air admitted. 

The estimated amount of air space necessary for one 
person is about 2000 cubic feet with a supply of about 
1500 cubic feet per hour. 

Now let us consider the sick person. If a fresh 
supply of air be necessary for an individual who is 
physically strong and in perfect health, how much 
more necessary is fresh air to a person whose body 
is debilitated by illness, whose vital processes are being 
hampered by high fever and toxins? How necessary 
is it to give free exit to the expired air, not only con- 
taining carbon dioxid and organic matter, but also the 
products of bacterial life, and in some instances bac- 
teria themselves? 

Ventilation of rooms is brought about in several 
ways. By disproportion between the temperature of 
the rooms and that outside ; by the natural diffusion 
of gases ; by openings allowing the free entrance and 
exit of air. We will deal only with the last mentioned 
means. 

There is a vast difference between draughts and ven- 
tilation. The former are a source of injury but the 
latter is not only not injurious, but very necessary. 
Some people think that in order to ventilate a room 
it is necessary to create a draught. 

There are two useful methods of supplying fresh 
air to the patient. The first is by continuous free 
ventilation ; that is, by having a large supply of air 
entering the room constantly. The second method 
consists in having a more limited constant supply, and 



HYGIENE OF THE SICK ROOM. 



23 



then several times a day, after covering the patient's 
body well and placing a thin cloth over his face, open- 
ing the windows widely for a brief time. 

In many modern dwellings the system of ventilation 




Fig. 4. — Window ventilation. A, A'. Inserted boards. 



is perfect and in these cases manipulating the win- 
dows is unnecessary, but as a general thing, ventilators 
in houses are such in name only. 



24 



FEVER NURSING. 



A very practical method of arranging the windows 
is as follows : Lower the upper sash from three to 
six inches, raise the lower sash the same distance, 
and fill in the open spaces, above and below, with 
pieces of board that exactly fit the window frame. 
At the center of the window there is then formed an 
air space between the lower part of the upper pane 
of glass and the upper part of the lower glass, and this 



—A 
B ,tf 



£.-- 



^ 

fc 



^Xm* 



w 



< 



< 



A 

t : 
l)/ 



..-">' 



JT 



H'^ X- 



ef 



Fig. 5. — Diagram of window ventilation (side view). A, A' window 
frame; B, B', inserted boards; C, C', window sash; E, E', window 
glass; H, H', currents of air going in and out. 



space communicates both with the outside air and the 
inside of the room to be ventilated. (See illustrations.) 



HYGIENE OF THE SICK ROOM. 2$ 

All kinds of flames, as in stoves, lamps, and gas 
jets, use up the oxygen of the air. These not only con- 
sume that which is of vital importance to the patient, 
but also vitiate the air with poisonous and oppressive 
gases. Do not burn more gas or oil in a sick room 
than is absolutely necessary. It is stated that an or- 
dinary gas burner in use consumes more oxygen in 
one hour than a person would use in six hours. 

Dr. Win. P. Northrup, of New York, has said: "If 
you wish to kill a child who is sick with pneumonia, 
close your windows, start the gas stove, burn a few 
gas jets, have plenty of friends in the room to help 
use the air, and have the temperature of the room 
above 8o° F." 

We have considered the quantity of air. Of next 
importance is its quality. The air should be of a cer- 
tain temperature. If the person be very feverish, the 
temperature of the room should be between 65 ° F. 
and 68° F., and when the temperature of the patient 
becomes normal or falls below the normal, the temper- 
ature of the room should approach 70 ° F. 

Perfectly dry air is very irritating to the respira- 
tory passages, and normally air should be a little moist. 
In houses heated by hot air furnaces it may be neces- 
sary to dampen the air. This is done by hanging in 
the room towels or cloths dampened with water; or 
in some cases, especially when the patient is ill with a 
disease of the respiratory tract, a steaming apparatus 
is very useful. Moisture may also be furnished by 
simply boiling water in the room. 

The Room and Its Furniture. — The room should 
be of fairly good size so as to provide plenty of air 
space. Southern exposure is to be selected if choice 



26 FEVER NURSING. 

be given. Plenty of sunshine will not only enliven 
and brighten the patient, but it also acts as a bacteri- 
cide. The eyes of the patient should not face the 
bright light. Only such furniture should remain in 
the room as is absolutely necessary — a bed., one or two 
small stands, and a couple of chairs. In cases of con- 
tagious diseases the pictures and curtain hangings 
should be removed. 

Do not allow unused glasses of water to remain 
in the sickroom, and plants and flowers should be ex- 
cluded. A very ill patient will not recognize or ap- 
preciate flowers, and if he wishes to see them they 
might be placed in an adjoining room within the sight 
of the patient. 

Preparation of Bed. — The proper preparation and 
care of the bed is one of the most important duties 
of the nurse. The principal considerations are that 
the bed should be neither hard nor soft ; the bed 
clothing should be smooth, and the coverings should be 
sufficient but light. 

Over a good hair mattress are smoothly placed, first, 
a soft blanket, then a cotton sheet. A draw-sheet is 
a very convenient addition. This consists of a sheet 
so folded as to be about three or four feet wide, placed 
crosswise on the undersheet and tucked in under the 
mattress at the sides. It should be placed so the 
buttocks of the patient be midway between the upper 
and lower edges of the draw-sheet. If necessary, a 
piece of rubber sheeting or table oilcloth may be 
put under the draw-sheet to protect the under bed- 
clothing from discharges. Over the patient should be 
placed a cotton soft sheet and a light blanket or quilt. 
Do not tuck these top pieces of bedclothing tautly 



HYGIENE OF THE SICK ROOM. 2.J 

under the sides of the mattress, for it is very annoying 
for the patient to have the clothing weight down or 
pull on the toes when he is in the supine position. 

The bedclothing of a fever patient should be changed 
without any active movement on the part of the 
patient. By means of a draw-sheet, the patient may be 
drawn from one side to another of the bed. When 
the soiled under-bedclothing may be rolled up as far 
as the body of the patient, and the clean clothing be 
applied over the uncovered portion of the bed, with 
the excess folded and placed beside the patient's body, 
then, by means of a draw-sheet, the patient may be 
lifted over the pile of soiled clothing, and the folds 
of new clothing on the freshly prepared portion of the 
bed, when the remainder may be adjusted and a new 
draw-sheet applied. 

Probably the most convenient form of body clothing 
for the patient is a short cotton gown, fastened at the 
back with tapes. 

Quiet. — Quietness in a sick room is very essential. 
Only those persons whose services are needful should 
be allowed in the room, and under no circumstances 
should any person outside of the immediate family 
and spiritual advisor be permitted to enter the room 
during the acute course of the disease. 

Loud talking and noises of all kinds should be pro- 
hibited both inside and outside of the room. All con- 
versation in the sickroom should be carried on in a 
low, soft voice, but not in a whisper. It is very unwise 
to converse in the sickroom in such a manner that the 
patient cannot hear it, for it at once arouses his cu- 
riosity and may excite him. If you have anything to 
say to the physician or attendants which the patient 



28 FEVER NURSING. 

should not hear, postpone saying it until you leave 
the room. 

In the acute fevers of children probably quiet is 
even more necessary than for adults. The child should 
rest quietly in bed and not held in the laps of elders 
and passed on from one to another, as this is very 
enervating and exhausts the little patient and may bring 
about a fatal issue, which otherwise could be averted. 
Attempts should not be made to entertain small chil- 
dren ill with one of the fevers, neither should they 
be urged to look at pictures or read to. Every chance 
should be given the recuperative powers to bring the 
little patient again to the state of health. 

The clothing of the child should be light, and swad- 
dling be relegated to the domain of ancient customs. 
The feet of all ill children should be kept warm by 
means of the hot-water bags, hot foot-blankets or 
heated irons or cloths. The room should be well venti- 
lated and the access of fresh air made free. 

The child should be urged to drink sufficient water. 
A daily morning cleansing bath of warm water is re- 
quired and a nightly warm bath is conducive of rest- 
fulness. A daily bowel movement is very important. 

The febrile disturbance in children is best met by 
means of a cool or tepid-water sponge followed by an 
alcohol rub, and by the employment of cold chest and 
abdomen packs. 

The diet, as in adults, should be reduced. 



CHAPTER III. 

DIET OF THE SICK. 

A foodstuff is that substance which, when introduced 
into the human body, is digested and assimilated, aids 
in the formation of new tissues, prevents the waste of 
tissue, or helps in the production of heat and energy. 

Food is a collection of foodstuffs to supply those 
elements necessary to maintain life. The five funda- 
mental foodstuffs are nitrogenous bodies, as proteids, 
carbohydrates, fats, inorganic salts, and water. The 
principal elements found in foodstuffs are nitrogen, 
hydrogen, oxygen, carbon, phosphorus, and sulphur. 

The proteids contain all the mentioned elements, 
and serve to form new tissues, supply nervous energy, 
and create heat. 

The carbohydrates contain hydrogen, oxygen, and 
carbon, provide heat or at times form fat, but cannot 
form other tissues. 

The fats contain the same elements as the carbohy- 
drates, and perform the same functions. 

The water and salts supply and keep up the normal 
percentages of these substances in the body. 

From what has been said above it will be easily 
understood that an absolute diet of fats and carbo- 

29 



30 FEVER NURSING. 

hydrates will not suffice, as these bodies do not supply 
nitrogen which is necessary for building new tissues. 
On the other hand, life may be sustained on a diet 
with these two foodstuffs omitted. 

The chief requisites of food are that it be well 
cooked ; that it be in good form ; be pleasing to the 
eye ; taste well, and contain in good proportion all 
those elements necessary to maintain life. 

Frequency of Feeding. — In acute infectious fevers 
food plays as important a part as medicines. It is 
in these cases that "support" of the patient depends on 
the food. 

During the course of the disease food must be given 
just as regularly as medicine, every two or three hours 
being usually frequent enough. About night feeding 
there is much debate, some authorities not wishing 
their patients awakened for food. It is an established 
fact that the vital functions are at their lowest in the 
early morning hours, and often a glass of milk or 
other nourishment has turned the tide for the better 
in adynamic conditions at this time. It is better to 
give the medicine and nourishment at the same time 
during the night, so as to avoid frequent awaking of 
the patient. 

Milk. — No one substance forms an ideal food, but 
of all substances milk comes nearest to being perfect. 
In milk all the elementary foodstuffs will be found. 
Proteid in the casein ; carbohydrates as milk sugar ; 
fats in the cream ; inorganic salts as calcium phosphate, 
potassium chlorid, etc. ; and water represented by the 
fluid portion. 

In fevers milk forms the sole diet. This subject has 



DIET OF THE SICK. 3 1 

been the cause of much debate and good points have 
been brought up on both sides. Those in favor of 
a milk diet say that life can be supported indefinitely 
on milk, that it is not irritating to the intestinal tract, 
that it leaves very little residue, that it is easily ob- 
tained and is cheap, that it is readily digested by most 
persons and if not, it may be artificially digested. 
Other authorities say that to many individuals milk is 
distasteful, it causes the formation of gas and tym- 
panites, that it does not contain in proper proportion 
the elements necessary to the sustenance of animal life, 
that the excess of lime salts predispose to thrombi 
formation, that in order to get sufficient nourishment 
enormous amounts must be given, which will over- 
burden the digestive apparatus. 

The daily amount of milk necessary is between three 
pints and two quarts. If five ounces of milk be given 
every two hours, it will, as a rule, be sufficient. Many 
persons cannot take undiluted milk. In these cases 
the milk may be diluted with lime water, barley water, 
oatmeal water, or vichy. 

In profound conditions the process of digestion 
must be aided. This may be done by giving pepsin 
and dilute hydrochloric acid after the administration 
of the milk, or by digesting the milk wholly or in 
part (See peptonized milk below). 

It is often necessary when nursing children are 
taken ill with a contagious disease, to cease feeding 
them with the milk from the mother's breasts, and 
to modify cow's milk so that it will approach the com- 
position of the mother's milk. Following will be found 
a convenient scheme for modifying cow's milk. 



32 FEVER NURSING. 

MODIFICATION OF COW'S MILK FOR INFANT FEEDING. 

I. Compositions of the Various Milks. 

PERCENTAGE OF 



II. 







FAT. 


SUGAR. 


PROTEID. 


00 


Cow's Milk, 


4 


4 


4 


(b) 


Gravity Cream, 


16 


4 


4 


(c) 


Human Milk (high) 


4 


7 


2 


(d) 


Human Milk (low) 


3 


6 


I 


. Feeding at Various Age 


5. 






(a) 


Birth to ist Month 


I 


6 


I 


(b) 


Birth to ist Month 


2 


6 


I 


(c) 


Birth to ist Month 


2 


6 


o.66 


(d) 


2nd to 4th Month 


3 


6 


i 


(e) 


4th to 1 2th Month 


4 


7 


2 


(f) 


After 1 2th Month 


4 


4 


4 



III. Daily Feedings and Amount of Milk. 

(a) ist Month, 8 Day and 2 Night Feedings, each 

2 Ounces. 

(b) 2nd Month, 8 Day and I Night Feeding, each 

3 Ounces. 

(c) 3rd Month, 8 Day and o Night Feedings, each 

4 Ounces. 

(d) 4th Month, 7 Day and o Night Feedings, each 

5 Ounces. 

(e) 6th Month, 6 Day and o Night Feedings, each 

7 Ounces. 

(f) 10th Month, 5 Day and o Night Feedings, each 

8 Ounces. 

IV. Total Daily Amount of Milk. 

(a) ist Month, 20 Ounces. 

(b) 2nd Month, 27 Ounces. . 

(c) 3rd Month, 32 Ounces. 



DIET OF THE SICK. 33 

(d) 4th Month, 35 Ounces. 

(e) 6th Month, 42 Ounces. 

(f) 10th Month, 40 Ounces. 

V. Methods of Obtaining the Various Composi- 
tions. 



(a) Formula 1-6-1. 

Parts. 
Milk, (2) 
Boiled Water, (6) 


Fat. 
8 



Sugar. 
8 



Proteid. 
8 



(8) 


8 


8 


8 


Sugar of Milk 5%, 


1 


1 
5 


1 



(b) Formula 2-6-1. 



Milk, 

Gravity Cream, 

Boiled Water, 


(2) 
(1) 
(9) 


8 

16 




8 

4 



8 

4 





(12) 


24 


12 


12 


Sugar of Milk 5 


2 


1 

5 


1 




2 


6 


1 


(c) Formula 2-6 


-0.66. 








Gravity Cream 


(2) 


32 


8 


3 



34 



\ 


FEVER NURSING. 






Milk, 


(1) 


4 


4 


4 


Boiled Water, 


(15) 













(18) 


36 


12 


12 




2 


0.66 


0.66 


Sugar of Milk 


5%, 




5 






2 


6(— ) 


0.66 


(d) Formula 4-7-2. 








Gravity Cream 


, (1) 


16 


4 


4 


Milk, 


(2) 


8 


8 


8 


Boiled Water, 


(3) 













(6) 


(24) 


12 


12 




4 


2 


2 


Sugar of Milk 


5%. 




5 






4 


7 


2 


(e) Formula 3- 


6-1. 








Gravitv Cream 


, (2) 


32 


8 


8 


Milk, 


(1) 


4 


4 


4 


Boiled Water, 


(9) 













(12) 


36 


12 


12 



3 1 1 

Sugar of Milk 5%, 5 

VI. An Example: The child is four months old 
and must be fed artificially. How will the nurse pre- 



DIET OF THE SICK. 35 

pare the milk? Tables II and III tell me that a child 
of four months will require 7 day feedings, each of 
5 ounces of a milk whose composition is 4-7-2. Table 
V (d) says this formula is made by taking I part of 
gravity cream, 2 parts of cow's milk, 3 parts of boiled 
water and 5% of milk sugar. 

Table IV shows that the amount to prepare for one 
day is 35 ounces. Therefore, take of gravity cream, 1 
part or 5 5-6 ounces; of cow's milk, 2 parts or 11 2-3 
ounces; of boiled water, 3 parts or 17 1-2 ounces; of 
milk sugar, 5% or 1 3-4 ounces. It is best to replace 
part of the water with lime water (2 or 3 ounces). 

Gravity cream is obtained by removing the cream 
from a vessel of milk which has been allowed to stand 
in a cool place, preferably on ice, for four or five hours. 

Eggs contain all elements, but the amount of car- 
bohydrates is very small. Eggs in the form of egg 
water or albumen water (see below) are very useful 
in fevers ; also as egg nogs, punches, and prepared in 
various ways. 

Meats are rich in nitrogenous material, and are 
useful chiefly in the forms of broths, consomme, etc. 

Meat broths have a tendency to cause diarrhea when 
given in fevers. For various meat recipes see below. 

Below is appended the recipes for preparing foods 
useful in the course or convalescence of fevers. 

RECIPES FOR SICK DIETARY. 

Barley Water. — (I) Mix one tablespoonful of 
barley flour with four tablespoonfuls of cold water, 
make a smooth paste free from lumps. Pour this into 



$6 FEVER NURSING. 

a pan containing one pint of boiling water and stir 
while boiling for five minutes. 

(II) Place one tablespoonful of pearl barley in a 
pan and add one pint of cold water and boil for a few 
minutes, then pour off the water and replace with one 
and one-half pints of clean water and allow it to sim- 
mer gently for one hour. Strain. 

Oatmeal Water. — To one pint of cold water add 
one tablespoonful of oatmeal and boil for three hours. 
Replace water as it boils away, and then strain. 

Arrowroot Water. — Make a paste of two table- 
spoonfuls of arrowroot powder with a small amount 
of cold water ; then add gradually, stirring constantly, 
one pint of cold water. Let it simmer for five or ten 
minutes. 

Albumen Water. — Strain the whites of several 
eggs through a cloth, add an equal amount of cold 
water, and stir well. A little lemon juice and salt may 
be added to taste. 

Toast Water. — Toast to dark brown, but do not 
burn, three slices of dry bread. Place in a dish and 
pour over them two pints of boiling water. Cover 
well and let stand on ice until cold; then strain and 
add sugar and flavoring agents. 

Rice Water. — Place two tablespoonfuls of cleaned 
rice in one quart of boiling water, and let simmer for 
two hours. Strain and add salt. 

Lime Water. — Place a piece of lime the size of a 
small egg in a quart, tight-stoppered bottle, and add 
a half-cupful of cool water; allow to stand over night 
and strain. To this washed lime add one quart of 
fresh cool water, shake occasionally and allow to stand 



DIET OF THE SICK. 37 

for twenty-four hours. The clear supernatant liquid 
is then ready for use. 

Flaxseed Tea. — Take of whole flaxseed one ounce, 
sugar one ounce, licorice root one-half ounce, and 
lemon juice one ounce. To these add one quart of 
boiling water and allow the whole to stand in a hot 
place for four hours. Strain and use. 

Imperial Drink. — To a quart of boiling water add 
two leved teaspoonfuls of cream of tartar, the juice 
of one lemon, sugar to taste, and serve cold. 

Raw Meat Juice. — Mince finely one pound of lean 
beef and place in a vessel with sufficient cold water to 
cover it. Let stand for four hours and strain through 
cloth. 

Wine Whey. — Bring one pint of milk to the boil- 
ing point and add one gill of sherry wine. Allow to 
stand in a warm place for ten minutes and strain. 
Lemon juice may be used instead of wine. 

Milk Punch. — To a glass of milk add two tea- 
spoonfuls of brandy or whiskey, and sweeten to taste. 

Junket. — To one pint of sweet milk add a pinch of 
sugarand two teaspoonfuls of liquid rennet, or a half- 
grain tablet of rennin, in a tablespoon ful of water, 
then pour into a proper receptacle and place near stove 
until coagulation begins, when it is cooled. 

Albumen Milk. — Mix equal parts of milk and albu- 
men water (see above), shake very thoroughly and 
serve at once. 

Oyster Milk. — Cook a quarter pint of oysters in a 
very small quantity of water for ten minutes, strain, 
and to the liquid add sufficient hot milk to make a 
pint. Salt to taste but add no pepper or butter. 



38 FEVER NURSING. 

Clam Milk. — Prepare same as oyster milk, using six 
clams to the pint. 

Boiled Custard. — Beat the yolk of two eggs with a 
tablespoon ful or more of sugar and a pinch of salt, 
and gradually add, with constant stirring, a pint of 
boiling milk, then cook until it thickens, probably four 
minutes. 

Egg Nog. — An egg is beaten well with a glassful 
of milk, and while stirring add a half-ounce of brandy 
or whiskey. 

Kumiss. — (I) Dissolve a half ounce of sugar in 
three ounces of water and twenty grains of yeast in 
three ounces of milk. Pour both into a bottle and add 
milk to make one quart. Cork and wire the bottle 
tightly, shaking at intervals daily for four days. 

(II) One quart of fresh milk, one-third of a cake 
of compressed yeast, one tablespoonful of sugar.. Mix 
the yeast with a little warm water, add the sugar to 
the milk, which should be lukewarm, then add the 
yeast and stir well. Bottle as above and set in a warm 
place for twelve hours ; then, after placing inverted on 
the ice for twelve hours, it is ready for use. 

Peptonized Milk. — To a pint of milk add five 
grains of pancreatin and twenty grains of sodium bi- 
carbonate which have been dissolved in one ounce of 
water. Keep at a temperature of no F. for one hour, 
then raise to the boiling point for a moment, and place 
on ice. 

Peptonized Beef Tea. — To one pint of beef tea 
add pancreatin and sodium bicarbonate as in peptonized 
milk, and keep at ioo° F. for three hours ; then strain 
and boil for one minute. 



DIET OF THE SICK. 



39 



Peptonized Oysters. — To one-half pint of oysters 
which have been finely minced, add pancreatin and 
sodium bicarbonate as in peptonized milk, keep at a 
temperature of ioo° F. for one hour, then add one pint 
of milk and keep at the same heat for another hour. 
Boil for one minute, strain, and salt to taste. 

Peptonized Toast. — To one piece of toast, cut in 
small pieces, add one pint of milk and mince thor- 
oughly; then add pancreatin and sodium bicarbonate 
as in peptonized milk. Raise to ioo° F. for two hours, 
then boil for a moment, and strain or not according to 
the condition. 

Farina Gruel. — Sprinkle slowly into a half-pint of 
boiling salted water two tablespoonfuls of farina and 
continue to boil for twenty minutes, using care that it 
does not burn or adhere to the pan; then gradually 
stir in sufficient hot milk to make a pint, and sweeten 
to taste. 

Gelatine. — Soak three level teaspoonfuls of granu- 
lar gelatine in a half-cup of cold water for fifteen 
minutes, then to it add sufficient boiling water to make 
a pint. Sweeten, flavor with lemon, strain, and set 
aside to cool. 



CHAPTER IV. 

REDUCTION OF FEVER. 

Fever is reduced by two methods, the use of drugs 
and by hydrotherapy. The first method we will not 
consider. 

Hydrotherapy is the use of water in the treatment 
of disease. Water is applied to the body in two ways, 
the mediate and the immediate. By the first method 
the water does not come in contact with the body as 
it is applied in receptacles made of rubber or water- 
tight tissues. By the immediate method the water is 
brought in direct contact with the skin. 

Mediate Method. — The ice-bag is probably the 
most common form of mediate application. These bags 




Fig. 6. — Ice-bag (Ashton). 

are made of thin rubber, or may be improvised at 
home by using the dried bladder of a pig or sheep. 
This makes a very good substitute for the rubber bag. 

40 



REDUCTION OF FEVER. 41 

Into the receptacle place a quantity of ice which has 
been cracked finely. Do not place too much ice in the 
bag, as it makes it very bulky and heavy, and it be- 
comes a burden to the patient. It is very difficult to get 
a good ice bag, as most of them will soon leak at their 
necks. Between the skin and the ice bag a soft, thin 
woolen cloth should be inserted, to prevent pain and 
necrosis of tissue — which have followed the neglect of 
this precaution. 

Instead of using ice, ice water may be used, but this 
method requires frequent changing as the water quickly 
becomes warm. 

Another similar method is that known as the ice 
poultice. Powdered ice is mixed with sufficient saw- 
dust to prevent dripping of water and the mixture is 
placed in a flannel bag and covered with oiled silk or 
oiled muslin. 

The cold water coil is a very good form for applying 
cold by the mediate process. This consists of a great 
length of small-caliber rubber tubing coiled in various 
shapes, depending on the part of the body for which 
it is to be used. A certain length at either end of the 
tube is not coiled, one end being used as an entrance 
for the water and the other as an outflow. The coil 
is applied to the body, particularly the abdomen, chest, 
and head, and the inflow end of the tube is placed in 
a pail of ice water elevated above the level of the body 
of the patient. The outflow end is placed in an empty 
pail on the floor. The water is started flowing by suc- 
tion on the outflow end. When the upper pail has 
been relieved of its water it is refilled from the lower 
pail. (See Fig. 7.) 



42 FEVER NURSING. 

The water bed consists of a large rubber mattress in 
which cold water is placed and the patient allowed to 
lie on it. This method is not frequently used. 

Immediate Methods. — The use of baths in the treat- 
ment of diseased conditions has long been in vogue, 
and, unlike other forms of ancient therapeutic meas- 
ures, has not fallen into disuse, but, on the other hand, 
is being employed more and more as time moves 
onward. 

The therapeutic indications for the use of baths are 
many. There is a false belief among many that the 
only value derived from the use of cold baths is the 
reduction of fever. This is entirely erroneous, for, 
although the lowering of high temperatures by means 
of cold baths is of great importance, however, it is not 
paramount. Cold baths are employed for the purpose 
of reducing fever, quieting delirium, calming restless- 
ness, overcoming insomnia, toning the nervous system 
and stimulating the vasomotor and circulatory func- 
tions. Most authorities do not employ hydrothera- 
peutic measures for antipyretic purposes until the tem- 
perature becomes 103° F. or more. To meet the other 
indications, cold is employed whenever these conditions 
are present, regardless of the temperature, unless it be 
subnormal. 

The forms of baths are many. Among the most em- 
ployed forms are the tub bath, bed bath, sponge bath, 
sheet bath, foot bath, and sits bath. 

Tub Bath. — As the name would indicate, this type 
of bath requires the use of a tub. In hospital practice 
the portable bathtub, which may be brought to the 
bedside, is very handy and makes this form of bath 






REDUCTION OF FEVER. 43 

less burdensome. In private practice the portable bath- 
tub is in most instances out of the question, and the 
patient must be made portable, which may prove seri- 
ous. The first consideration is the transporting of the 
patient to the tub. With the aid of one assistant this 
may be easily accomplished with a not too ponderous 
patient. It must be firmly impressed upon the patient 
that he is to exert himself in no way, and is to re- 
main entirely passive. Another method is by placing 
the patient on a light stretcher while in bed, and carry 
him to the tub. Some of the portable bathtubs are 
provided with a stretcher and a frame by which the 
patient may be easily lowered into and raised from 
the water by means of a crank. The next point of 
importance is the temperature of the water. Shall the 
patient be placed in cold water at once or not? This 
is a much debated question. The shock due to sudden 
immersion into cold water is advocated by some physi- 
cians as being very beneficial, whereas, others say this 
shock is detrimental and should be avoided by placing 
the patient first in warm water and then gradually 
lowering the temperature of the water. It may be 
accepted as a safe rule, that patients that are robust 
and not overwhelmed by the disease from which they 
are suffering may be placed at once in the cool water. 
Before bathing debilitated or weak patients it is wise 
to administer a transient stimulant, as spirit of ether 
or aromatic spirit of ammonia. The temperature of the 
water should be 70° F. and should be kept at this point 
by adding cold water from time to time, or by means 
of ice in a cloth bag placed in the water. The tem- 
perature of the water is raised by the abstraction of 



44 FEVER NURSING. 

heat from the body. It is very important that the 
surface of the patient's body be constantly rubbed, so 
as to maintain the peripheral circulation. 

Friction of the surface is absolutely necessary, as it 
prevents chilling and internal congestions, and also aids 
in more rapid elimination of heat. An ice cap placed 
on the head will obviate troublesome cerebral conges- 
tion. 

The patient should remain in the water fifteen or 
twenty minutes or until the temperature is reduced to 
100.5 ° F. After the patient is removed from the cold 
bath the temperature may continue to fall, and if 
lowered below 100.5 F. by the bath, he may later 
enter collapse. 

When the bath is completed the patient should be 
gently dried, placed in bed and covered only with a 
sheet. If chilliness continues for any length of time, 
a few hot-water bottles may be placed around the 
lower extremities of the patient. 

In conclusion let me repeat two maxims : Constant 
friction or rubbing of the surface is important. Do 
not reduce the temperature below 100.5 F. 

Bed Bath. — This is really a tub bath applied to a 
patient in bed. It is useful, in that the patient is not 
removed from his bed, and the results are about as 
good as those derived from a tub bath. 

The bed bath is easily arranged. A rubber sheet 
of large size is first placed under the patient, then a 
large blanket is rolled lengthwise, so as to form a large 
bolster, which is then placed under the side of the 
rubber sheet and running parallel with the patient's 
body; a second blanket is arranged as the first but 







c< 



< £>" 






REDUCTION OF FEVER. 45 

placed under the rubber sheet on the opposite side of 
the patient; this forms a trough in which the patient 
lies, the ends of the tub are formed by placing one or 
two pillows under the ends of the rubber sheet. The 
pillows at the head of the tub will also act as a support 
to the patient's head. The tub being complete, water 
may now be poured into the improvised rubber bath 
tub. (See Fig. 8.) 

It is well to have a cotton sheet under the patient, 
to prevent the body from coming in contact with the 
harsh rubber sheet. 

The bath is given in the same way and with the same 
precautions as a tub bath. 

When the bath has been completed the water is re- 
moved by taking away a part of the foot pillow and 
lower end of the side bolster, and thus form a sluice 
for the escape of water into a pail held under the gate. 
The rubber sheet is then removed, the patient gently 
dried and covered with a light sheet. 

I consider this form of bath a most excellent one 
for many obvious reasons. The patient is not dis- 
turbed, and the tub may be easily and quickly impro- 
vised in any house. If a rubber sheet is not handy, 
a large piece of table oilcloth will serve the same 
purpose. 

Sponge Bath. — This is one of the most used and 
beneficial forms of hydrotherapeutic measures. Many 
practitioners prefer the sponge bath to all other baths 
and have it used exclusively in the treatment of their 
fever patients. 

A rubber sheet is first placed under the patient, then 
with a moist sponge the surface of the body is covered 



46 FEVER NURSING. 

with a thin film of cold water. If the water is applied 
in this manner, evaporation, hence heat elimination, 
results more rapidly than were the patient deluged with 
water. It is necessary to constantly apply friction to 
the body surface to maintain the peripheral circulation 
and to aid evaporation. 

In weak and timid patients it may be wise to sponge 
only part of the body at a time. 

It is necessary to sponge and rub the back, for it 
is here that passive congestions occur, and much heat 
is stored in the thick tissues of these parts. 

Sheet Bath or Packs. — With this form- of bath I have 
obtained more beneficial results than with the tub or 
sponge baths in selected cases. 

An arrangement similar to the bed bath, but more 
shallow, may be made, or simply place a rubber sheet 
or piece of table oilcloth under the patient. The pa- 
tient is then wrapped in an ordinary sheet from "chin 
to toes," and sprinkled with cold water until the sheet 
is thoroughly wet, then rub the patient's- body actively. 
This is important. x-\s the sheet becomes warm, pour 
on more cold water. 

In ten or fifteen minutes the wet sheet and rubber 
cloth are removed and the patient covered with a light 
cotton sheet. 

Foot Baths. — The uses of this form of bath differ 
from those discussed above. The foot bath or pedi- 
luvium is used principally to influence the circulation 
of the body in insomnia, headaches and beginning acute 
diseases, and also as a means of relieving local pains. 

The feet, and legs nearly to the knees, are placed in 
a deep tub of hot water, and more hot water is added 






REDUCTION OF FEVER. 47 

as the parts become accustomed to the heat. This 
soaking is continued for ten or fifteen minutes. 

Mustard if added to the water will enhance the 
action. Use one ounce of mustard-flour to a gallon of 
warm water. 

Sits Bath. — This form of bath is taken in the sitting 
(sits) posture and is used to influence the pelvic cir- 
culation. It is employed in suppression of menstrua- 
tion, dysmenorrhcea, chordee, etc. 

The buttocks are immersed in hot water. A blanket 
is wrapped about the upper part of the body and draped 
over the tub, to prevent the loss of heat. The patient 
remains in this position about fifteen minutes. 

Temperature of Baths. — 

Hot, no 

Warm, 98 ° 

Cool, 88° 

Cold, 70 

Notes on Bathing. — It is not wise to continue a bath 
more than from twenty minutes to a half-hour. Do 
not reduce the temperature of a patient below 100.5 ° 
F. as collapse may result. Do not wait for the time 
or temperature limit if the patient become depressed 
or enters collapse, but remove the patient at once and 
apply stimulants. 



F. 


to 


IOO° 


F. 


F. 


to 


88° 


F. 


F. 


to 


yo° 


F. 


F. 


to 


So° 


F. 



CHAPTER V. 

ALLEVIATION OF SYMPTOMS. 

In this section the medicinal or drug treatment of 
disease will not be considered, it being left to the dis- 
cretion of the attending physician. Only such treat- 
ment will be discussed as a nurse may employ in the 
absence of the physician. Not only symptoms but also 
some of the complications will be given attention. 

Bed sores occur in all diseases in which prolonged 
rest in bed is necessary. They are very common in 
some diseases, especially typhoid fever. 

They are due to interference with the circulation, 
as the result of pressure, and hence the nutrition of 
the skin is cut off, a sore resulting. They occur most 
frequently over the bony prominences. Moisture acts 
as an exciting agent ; also hard particles on the sheets, 
such as crumbs. Creases in the bed clothing and de- 
pressions in the mattress tend to aggravate the sores. 

The treatment of this common occurrence is two- 
fold : preventive measures, curative measures. 

Preventive measures must, of course, be used before 
the formation of the sores. Cleanliness is paramount, 
and frequent changes in the position of the patient 
are essential. Do not allow a patient to lie too long 
in any one position. A change of position is restful. 

Hardening of the skin is a most important preven- 
4 8 



ALLEVIATION OF SYMPTOMS. 49 

tative. This is augmented by bathing those parts of 
the body where bed sores are usually formed, with var- 
ious hardening and astringent solutions. Dilute or 
full strength alcohol (not absolute alcohol) are very 
good agents, or a solution consisting of whiskey and 
common salt (i to 753). Vinegar is very useful. A 
simple and handy way is to take a slice of lemon and 
rub this over those parts that might be affected, repeat- 
ing daily. This will prevent bed sores, when other 
methods fail. Solutions of alum and tannic acid have 
been used. 

Curative Measures. — After sores have formed active 
treatment is necessary. The sores should first be thor- 
oughly cleansed with a solution of peroxid of hydrogen 
or bichlorid of mercury (1-5000) and then dressed dry 
with some dusting powder, as bismuth subnitrate, aris- 
tol, or stereate of zinc. If the sores show signs of 
indolency, touch them with a stick of silver nitrate 
and dress with ichthyol or balsam of Peru. 

Constipation is the rule in most febrile diseases 
and is due to numerous causes, among which are the 
prolonged rest in bed, the diet of milk, and in some 
cases the medication. 

The constipation is best relieved during the acute 
course of the disease by means of enemata, of which 
there are several kinds. (For the composition of ene- 
mata see that section in the Addenda.) 

Convulsions occur frequently in children ill with in- 
fectious fevers. The very best and rapid method of 
overcoming convulsions is to place the child in a hot 
mustard bath. If the child's temperature be very high, 
this may be the cause of the convulsion. Then cold 
4 



50 FEVER NURSING. 

water may be poured over the child while in the bath 
If there be any reason to believe the attack to be due 
to meningitis, apply ice to the head. 

An enema should be given if the child were pre- 
viously constipated. 

Diarrhea may be very troublesome, especially in 
typhoid fever. Most authorities say that when the 
movements of the bowels number more than six in one 
day, active treatment should be begun. 

In many cases diarrhea can be controlled by applying 
a mustard plaster to the abdomen. In some instances 
it may be necessary to wash out the lower bowel by 
means of a normal saline solution. A rubber tube or 
catheter of large caliber is introduced high in the rec- 
tum and the solution allowed to flow in from a foun- 
tain bag. Free exit for the returning solution must be 
provided by the introduction of a second catheter of 
smaller caliber than the inflow one. 

Ice water injections have been advocated by some 
but should be reserved for very strong individuals. 

Starch and laudanum enemata. (See Addenda.) 

Delirium occurs in two forms — the active and the 
low muttering forms. In the former the patient be- 
comes more or less maniacal and wild. This is rare 
in the infectious fevers, and as a rule the patient is one 
who has been addicted to the use of alcoholic beverages. 

The active form is combatted by powerful sedative 
drugs. The low muttering form of delirium is best 
treated by hydrotherapeutic measures, as baths, packs, 
etc. ; also by alcoholic stimulation. 

Disorders of the Tongue and Mouth. — In all cases 
of febrile disease careful attention should be paid to 



ALLEVIATION OF SYMPTOMS. 5 1 

the mouth, tongue, and teeth. The latter should be 
kept thoroughly clean. The mouth is to be cleansed 
several times daily by swabbing it with cotton or gauze 
wet with some antiseptic solution. A very useful solu- 
tion consists of glycerine, 5 parts; lemon juice, I part; 
hydrogen peroxid, 5 parts ; water. 25 parts. A solu- 
tion of boric acid or borax may be used or a diluted 
solution of hydrogen peroxid. 

Fever. — See special chapter. 

Headaches are very common in the onset of all 
infectious fevers, and are very annoying to the patient. 
An ice bag applied to the head will relieve the majority 
of headaches. A cold bath or pack are useful in some 
instances. If the bowels are constipated, an enema 
will be of great service. A mustard foot bath often 
gives good results. 

Hemorrhage from the Bowels. — This occurs as a 
complication of typhoid fever in over four per cent of 
cases. It is a serious occurrence and demands prompt 
and active treatment. The signs and symptoms of 
intestinal hemorrhage are discussed in the chapter on 
Complications. 

The attending physician should be notified at once. 
In the meantime apply an ice-bag to the right iliac 
region of the abdomen ; stop all nourishment by mouth 
and enforce absolute quiet. Prepare for giving a hypo- 
dermic of morphin in case the physician might wish 
it ; also get the apparatus and solutions ready for giv- 
ing a hypodermoclysis. 

Hemorrhage from the Lungs. — In pulmonary dis- 
ease, especially in ulcerative tuberculosis of the lungs, 
hemorrhage is of somewhat frequent occurrence. 



52 FEVER NURSING. 

The treatment is similar to that for hemorrhage from 
the bowels. Place an ice-bag on the chest and prepare 
for a hypodermic of morphin, and for a hypodermocly- 
sis if the bleeding has been profuse. 

Hemorrhage from the nose or epistaxis may be very 
severe and persistent in typhoid fever and other infec- 
tious fevers. It is best combatted by first applying 
warmth to the feet by means of hot water bags or a hot 
mustard foot bath. Hot water bags should also be 
applied to the back. Ice, or cloths which have been 
on ice, are applied to the root of the nose. Spray or 
douche the nose with vinegar or diluted lemon juice. 
Douching the nose with very warm saline solution is 
as useful as any method. 

Insomnia is a frequent and very troublesome 
symptom of the infectious fevers. If the temperature 
be high, a sponge bath with cool water, or an alcohol 
rub will relieve the feverishness, quiet the nervous sys- 
tem, and be productive of good results. At times a 
sponge with tepid or warm water will be more useful 
than with cool water. A hot foot bath, or hot water 
bottles applied to the feet are also good. An ice-bag 
to the head may be used in conjunction with this 
method, or alone. 

In many cases a hot drink before the hour of sleep 
will aid in the production of sleep. 

Nephritis occurs often as a sequel of scarlet fever 
and erysipelas (see Complications) and is of grave 
import. The indications are to restore the functionat- 
ing powers of the kidneys and to relieve them of part 
of their duties. This latter is obtained by increasing 
the elimination of water by the skin and bowels. 



ALLEVIATION OF SYMPTOMS. $3 

Increased elimination of water by the skin is brought 
about by augmenting the excretion of sweat. The 
patient should be placed between blankets with plenty of 
hot water bottles about him. Sweating may also be 
increased by giving the patient a hot air bath. Intro- 
duce under the blanket in which the patient is wrapped, 
the end of a tin pipe, the other end of which contains 
an alcohol lamp placed on the floor. (See Fig. 9.) If 
sweating does not occur, it may be hastened by admin- 
istering a drink of cold water. 

When applying heat to an extensive surface of the 
body it is well to have an ice bag on the head to pre- 
vent cerebral congestion or heat stroke. 

Plenty of water must be introduced into the system 
as this aids in the return of power to the kidneys and 
also flushes them of irritating material and toxins., 
Water may be introduced by drinking or by saline 
infusions per rectum or by hypodermoclysis. The bow- 
els should be moved by the aid of calomel or epsom 
salts. 

Hypodermoclysis, or literally, an injection under 
the skin, is one of the most useful procedures in the 
treatment of certain serious and grave conditions. 

The liquid injected is a watery solution of common 
salt, of a determined strength, and is known as a 
physiological salt solution, normal saline solution, nor- 
mal salt solution and isotonic salt solution. This 
solution is a 0.6 per cent, to 0.9 per cent, solution of 
salt (sodium chloride) in water, and is so called be- 
cause it is of the same saline strength as human blood 
serum. This solution is prepared by adding one and 



54 FEVER NURSING. 

one-half drams of common salt to one quart of 
water. The solution must be sterile. A more con- 
venient method is to have on hand a sterile, concen- 
trated salt solution, and prepare the injecting fluid by 
adding a small amount of the concentrated salt solu- 
tion to one quart of sterile water. The concentrated 
solution is prepared by dissolving six ounces of com- 
mon salt in one pint of water and thoroughly sterilizing 
it. One-half ounce of this solution added to one quart 
of sterile water will produce a normal salt solution. 

The introduction of normal saline solution into the 
system restores the blood serum to the normal amount, 
tones the vasomotor system, stimulates the heart, 
amends the body heat, aids in the elimination of tox- 
ines and deleterious material through the skin and 
kidneys. 

The indications for the employment of hypodermo- 
clysis are cardiac failure, especially when accompanied 
by vasomotor disturbances, as in shock, collapse, ether 
and chloroform narcotization, post-operative shock, de- 
pressions during acute diseases, as pneumonia and 
typhoid fever. Loss of body fluids, as in severe 
hemorrhages and exhausting diarrheas, and in post- 
operative thirst. Toxemias and disease characterized 
by circulating poisons-, uremia, etc. Nephritis accom- 
panied with anuria. 

Method of Procedure. — Various forms of apparatus 
have been devised with which a saline injection may 
be given. A simple, inexpensive and readily obtain- 
able apparatus consists of a quart glass funnel, a piece 
of rubber tubing and a fair-sized aspirating needle, 
or a fountain rubber bag, with its tubing, and an aspi- 



ALLEVIATION OF SYMPTOMS. 55 

rating needle may be employed. This apparatus should 
be used for no other purpose. The outfit must be 
absolutely sterile before being used. 

The normal saline solution, which should be sterile 
and at a temperature of 103° F., is poured into the 
glass funnel ; a stream of the solution is allowed to 
run from the needle until all air is removed from the 
tubing and the solution has warmed the apparatus. 
Between the thumb and index finger of the left hand 
raise a fold of the patient's skin at the site for the 
injection, preferably below the breasts, the side of the 
abdomen or inner part of the thigh, and with the right 
hand thrust the needle point through the skin at the 
base of the fold into the loose subcutaneous tissues. 
The funnel is elevated about three feet above the 
patient, and the solution allowed to enter the tissues. 
As the parts begin to swell, they should be gently 
rubbed, to diffuse the solution and aid in its absorption. 

After one and one-half pints of the solution have 
entered the tissues the needle is withdrawn and a small 
piece of adhesive plaster applied to the area. 

It is often necessary to repeat the injections one or 
more times. The author has witnessed most excellent 
results from the regularly repeated saline injections. 

Enteroclysis. — The injection of large amounts of 
fluid into the bowel has long been in vogue. It is a 
highly useful method of supplying fluid to the body 
after severe hemorrhage, persistent diarrhea, post- 
operative thirst, and when it is not practicable to give 
water by mouth, in certain stomach disorders. 

In certain forms of nephritis, when the kidneys are 
excreting but little urine, enteroclysis of normal saline 



56 FEVER NURSING. 

will often produce very good results. In toxemias, 
diabetic coma, uremia, gas poisoning, acute infectious 
diseases and all conditions characterized by circulating 
poisons, enteroclysis of normal saline will dilute the 
poisons and aid in the elimination. A patient suffering 
from severe toxemia was placed under my charge, in a 
moribund condition. I immediately began to irrigate 
the bowel with normal saline solution, and was soon 
gratified by an improvement in the patient's condition, 
which slowly continued until full return to conscious- 
ness resulted. In six hours I used over fifty gallons 
of saline solution. 

In intestinal diseases, such as dysentery, cholera and 
infantile enterocolitis, enteroclysis of medicated solu- 
tions is most beneficial. 

In infantile diarrheal conditions, washing of the 
lower bowel will give most gratifying results. 

Method of Procedure. — The saline solution is pre- 
pared as described under Hypodermoclysis. The ap- 
paratus used is the same, excepting that the aspirating 
needle is replaced by a double-flow apparatus of some 
kind. A double-flow arrangement which I have found 
of much service is known as the Martin rectal irri- 
gator. The inflow tube is connected with the rubber 
tubing from the funnel or fountain bag, and the out- 
flow tube is connected with a piece of rubber tubing 
leading to a waste pail. 

When it is desired that the injection be given high in 
the bowel, a long double-flow tube may be easily im- 
provised. A rubber rectal tube with an open end, as 
well as a side eye, and a small-caliber soft rubber 
catheter are necessary. The catheter is passed through 



ALLEVIATION OF SYMPTOMS. 57 

the rectal tube until the eye of the catheter projects 
just beyond the end of the rectal tube, and is here 
secured with a stitch of silk. The catheter serves as 
the inflow tube and the rectal tube as an outlet. 

When employing enteroclysis on a child or infant, 
use a soft rubber catheter instead of a rectal tube, and 
secure sufficient outlet. 

The temperature of the solutions used should be 
about ioo° F. 

Pains in the back are very troublesome in influ- 
enza. The application of strong mustard paste, hot 
water bags, or an ice-bag are useful. 

Pains in the joints are the most annoying symp- 
toms in rheumatism. The applications for local con- 
trol of joint pains are varied and numerous. Every 
physician, nurse, and housewife has many original pain- 
killers. The following are a few of the many and are 
the best: 

A very good application consists in oil of gaultheria, 
one ounce; salicylic acid, one dram, and cotton seed 
oil, twelve ounces. Apply to joint and cover with soft 
woolen cloths and oiled muslin. 

A mixture of equal parts of guaiacol and glycerin 
applied as above is very useful. Ichthyol, either pure 
or as a fifty per cent ointment. Hot cloths saturated 
with the lotion of lead and laudanum. Chloroform 
liniment is good. 

A most excellent method is the application of an ice 
bag. The mention of this is disagreeable to the patient, 
but after a few minutes application the pain becomes 
easier and the patient more comfortable. 



58 FEVER NURSING. 

A method used by some physicians is to make wool- 
len bags and place a moderate amount of powdered 
sulphur in each and draw them over the affected limb 
and shake them so that the sulphur gets over the sur- 
face of the limb. Allow the bags to remain on for a 
few days. This method acts better in the subacute 
cases. 

Peritonitis. — The application of a light ice bag 
to the abdomen is the best. 

Pleurisy or "Stitch in the side," when it occurs, 
is very annoying to the patient. A hot water bag or 
a mustard plaster placed over the area will generally 
give relief. An ice bag is fully as good as the hot 
water bag, and in many cases it produces the best of 
results. The application of an ice bag is repulsive to 
most patients but as they soon learn the great results 
obtained from its use they do not object after the first 
application. 

Tincture of iodin painted over the area of pain is very 
useful. A belladonna plaster does good in some cases. 

Retention of Urine is not of uncommon occur- 
rence in the acute febrile diseases, and should not be 
confused with suppression of urine. In the former 
the kidneys may be performing their functions nor- 
mally and secreting the proper amount of urine, which 
is collected in the bladder, but the patient is unable to 
pass it from this viscus ; but in suppression of urine the 
kidney function is disturbed and little or no urine is 
secreted, and the bladder remains free from urine. 
This latter is a very serious condition. 

Before resorting to the use of a catheter in urinary 
retention, other simpler means should be employed. 
Ofttimes retention is of nervous origin, the patient 



ALLEVIATION OF SYMPTOMS. 59 

being unable to pass urine if the nurse or other person 
remain in the room, but readily accomplishes the act 
if left alone in the room. The sound of running 
water from an open faucet often helps ; the application 
to the lower abdomen and genitals of cloths wrung out 
in hot or cold water is often successful in starting the 
flow of urine. Placing hot water in the bedpan, so 
the steam reaches the parts, will sometimes aid. When 
all simple means fail, resort to the catheter is oblig- 
atory. Of catheters there are two kinds, the rigid 
and the flexible. The rigid are made of metal or 
glass, and the flexible of soft rubber or webbing. 

In catheterization, two things should be ever kept in 
mind : The catheter must be sterile ; the patient's parts 
and the nurse's hands must be clean. Rigid catheters 
are sterilized by boiling, and the flexible catheters are 
rendered sterile by immersing for twenty minutes in 
1- 1000 bicloride of mercury solution, and thoroughly 
rinsed with sterile water before using. 

The parts of the patient are cleansed with soap and 
warm water and then swabbed with strong boric acid 
solution. 

Catheter fever and cystitis may result from improper 
catheterization. 

If the bladder is greatly distended with urine, it 
should be only partially emptied, as complete removal 
of the urine may bring about collapse. 

Sore Throat is troublesome in some of the infec- 
tious fevers, especially in scarlet fever and diphtheria. 
External applications to the throat of heat and cold, 
especially the latter if the patient will submit to it, 
should be used. 

For internal use, that is, as gargles or for swabbing 



60 FEVER NURSING.' 

the throat, the following are useful : Hydrogen perox- 
id solution (i to 3). Solution of boric acid (1 to 25). 
Tincture of chlorid of iron one dram, glycerin one 
ounce, and water to two ounces. 

Sweating of a profuse type occurs in some cases 
of typhoid fever, usually due to exhaustion or sep- 
sis; in tuberculosis pulmonalis and acute rheumatism. 
Sponging the body with the following solution is very 
good : Alum one-half ounce, alcohol two ounces, water 
sixteen ounces. 

A wash of vinegar or of one dram of sulphuric acid 
to one pint of water, is often valuable. 

Tympanites is especially prominent in typhoid 
fever. The abdomen sometimes reaches a great size, 
and the tympanites becomes a very serious complica- 
tion. 

Intestinal antiseptics administered by mouth aid 
greatly in decreasing the distention. Of all drugs used 
turpentine stands in the first rank. It should be used 
internally and externally. 

Externally it is used in the form of stupes. For 
instructions on making these see the article on Topical 
Applications. A turpentine enema is of very great help 
in expelling gas. (See section on Enemata.) 

Turpentine used externally is absorbed to a certain 
extent and a continuous use of it may be followed by 
toxic effects. Careful watch must be kept to detect 
the onset of poisonous symptoms. Turpentine is irri- 
tating to the kidneys, and the urine is a means of de- 
tecting its ill effects. The odor of the urine becomes 
like that of violets ; later the urine may become cloudy 
and bloody. Cyanosis may occur. In many persons 
it will cause a diffuse, red eruption of the skin. 



ALLEVIATION OF SYMPTOMS. 6 1 

Asafetida is very useful in aiding the escape of flatus, 
if given as an enema. (See Enemata.) 

Vomiting is a very distressing symptom and at 
times it seems almost uncontrollable. In many of the 
most severe and protracted cases simple measures have 
brought about the best results. An ice-bag placed on 
the back, epigastrium, or nape of the neck is of service. 
A mustard poultice over the epigastrium works mar- 
vels. Cracked ice with whiskey or champagne is ben- 
eficial. Lime water added to the milk relieves the 
stomach in many instances. 

Inhalations from a cloth wet with vinegar, a starch 
and laudanum enema, and washing of the stomach (in 
selected cases) are useful. 

In some cases it will be necessary to temporarily 
stop feeding by the mouth and to rely on rectal ali- 
mentation. (See Enemata.) 

Shock and Collapse. — Below is given a tabulated 
arrangement for the application of remedial measures 
to overcome shock and collapse. 

Elevate the feet and lower the head. 

Apply warmth by means of blankets and hot water 
bags. 

Give diffusive stimulants, as aromatic spirits of am- 
monia, spirits of ether, whiskey or brandy. 

Give stimulants by hypodermic, as strychnin, atropin, 
nitroglycerin, digitalin, and suprarenal solution. 

Amyl nitrite by inhalation is very useful in some 
cases. 

Saline solution subcutaneously or by rectum. 

Rectal injections of a cup of strong, black coffee 
are good. 



CHAPTER VI. 
DETECTION OF COMPLICATIONS. 

During the course of the infectious fever, complica- 
tions are not only frequent, but in many instances 
increase the gravity of the primary disease. They 
may occur during any stage of the disease, from the 
invasion to convalescence. An early knowledge of the 
onset of complications is important, and their detec- 
tion is only accomplished by continued and careful 
study of the patient's condition. A great part of the 
burden is dependent on the nurse in attendance, as 
the complications generally make their appearance 
during the absence of the physician. 

The more common complications of each of the 
infectious fevers are classified, and then the more im- 
portant complications are discussed in detail. 

Typhoid Fever. — Intestinal hemorrhage, intestinal 
perforation, bed sore?, severe bronchitis, phlebitis, 
grave delirium, excessive diarrhea, cholecystitis, bone 
lesions, pleurisy, pneumonia and septicemia. 

Smallpox. — Laryngitis, bronchopneumonia, albu- 
minuria, myocarditis, otitis media and iritis. 

Scarlet Fever. — Nephritis, arthritis, endocarditis, 
otitis media, meningitis, pericarditis, pleurisy and 
convulsions. 

62 



DETECTION OF COMPLICATIONS. 63 

Measles. — Bronchopneumonia, otitis media, laryn- 
gitis, severe bronchitis, paralysis, pleurisy, diarrhea and 
convulsions. 

Mumps. — Meningitis, nephritis, arthritis, orchitis, 
ovaritis, facial paralysis and otitis media. 

Whooping-cough. — Pneumonia, nephritis, convul- 
sions, hemorrhages into the skin, conjunctivae and from 
the nose and bronchi. 

Influenza. — Pneumonia, pleurisy, meningitis, neu- 
ritis, nephritis and nervous disorders. 

Cerebrospinal Meningitis. — Pneumonia, arthritis, 
paralysis, nephritis, pericarditis, endocarditis and otitis 
media. 

Lobar Pneumonia. — Pleurisy, edema of the lungs, 
pericarditis, meningitis, delirium, convulsions and 
empyema. 

Diphtheria. — Paralysis, endocarditis, pericarditis, 
pneumonia, nephritis, severe bronchitis, arthritis, 
otitis media and abscesses. 

Articular Rheumatism. — Endocarditis, pneumonia, 
pleurisy, delirium, meningitis, purpura and convulsions. 

Erysipelas. — Pneumonia, endocarditis, delirium, 
pleurisy, meningitis, pericarditis and septicemia. 

Important Complications. 

Arthritis may occur during the course of any of 
the acute infectious fevers, particularly in scarlet 
fever, diphtheria, cerebrospinal meningitis and typhoid 
fever. Any of the joints may be affected. The 
severity of the arthritis varies exceedingly. In scarlet 
fever I have seen instances of involvement of the 



64 FEVER NURSING. 

shoulder joint which disappeared in eighteen hours, 
although at a previous visit the symptoms seemed 
almost unbearable. Cases of arthritis of the hip joints 
following typhoid fever, which completely destroyed 
the joint. The inflammation may be of the simple 
serous type or may be suppurative and destructive. 
One or more joints may be involved. The disease may 
manifest itself with swelling and redness of the parts 
and great pain and tenderness. 

Bed Sores may occur during any acute infectious 
disease which prostrates the patient, or during the 
course of which the patient is required to remain in 
bed for a protracted time. Bed sores occur frequently 
in typhoid fever. Bed sores result from pressure or 
disease of the nerves or cord. Pressure acts as an 
exciting cause in two ways — by mechanical damage of 
the tissues, or by interfering with nutrition and blood 
supply of the part. The sores first appear as red, 
glossy area over bone prominences, as the sacrum, ilia, 
or heels, and may be prevented from entering the 
second stage by removing the cause, by the use of 
astringing and hardening lotions and by hydrothera- 
peutic measures (see Chapter V). Soon the continuity 
of the skin is destroyed and an abrasion results, which 
passes into the ulcerous stage and may become quite 
extensive. 

Bronchitis of a severe type is not an uncommon 
complication of typhoid fever, measles and diphtheria. 
In typhoid fever this complication is troublesome be- 
cause of the cough, which, when very severe, may 
urge intestinal hemorrhage. Bronchitis, when com- 
plicating one of the acute fevers, is recognized by the 



DETECTION OF COMPLICATIONS. 65 

cough, which at first is tight and painful, and later 
accompanied by more or less profuse expectoration. 
The fever of the primary disease may be greatly ex- 
aggerated by the advent of bronchitis. Chills or chilly 
sensations are frequent. 

Convulsions occur very frequently in the acute 
infectious diseases affecting children, as pneumonia, 
scarlet fever, measles, whooping-cough and influenza. 
In adults convulsions may vary from a slight twitching 
of one member to a general convulsion resembling the 
epileptic seizure with the glottic spasm, rolling eye- 
balls, clenched hands, stiff neck, etc., terminating in 
unconsciousness. 

Delirium may occur in any of the acute infectious 
fevers, and is frequent in typhoid fever, pneumonia, 
erysipelas and rheumatic fever. Delirium is met with 
in two forms — the quiet, low-muttering form, and the 
loud, active form. In typhoid fever the delirium, as 
a rule, is of the low-muttering type. The patient be- 
comes apathetic and semi-conscious, and will pick at 
the bedclothes (carphologia) or attempt to catch imag- 
inary bodies. The patient may lie unconscious with 
the eye staring, fixed upon one object (coma vigil). 
In rare cases of typhoid fever the delirium may be of 
the active type, the author having seen cases in which 
the patient was very restless, later becoming active, 
wild and noisy, and tried to escape by throwing him- 
self through a window. 

Delirium in pneumonia may be of either type, and 

in patients accustomed to alcoholic beverages it may 

become of the character of delirium tremens (mania a 

potu). Delirium is not uncommon in rheumatic fever, 

5 



66 FEVER NURSING. 

and may be due to high fever, the action ot the toxines 
on the nervous system or to the administration of the 
salicylates (see Chapter XIX). 

Diarrhea. — Diarrhea of an excessive and exhaust- 
ing type ceases to be a symptom and becomes a com- 
plication. In typhoid fever especially, and sometimes 
in measles, this complication is met. Excessive diar- 
rhea exhausts and weakens the patient and prolongs 
convalescence. 

Edema of the Lungs may occur as a complication 
in pneumonia or as an antemortem phenomenon in any 
acute infectious fever which has run a severe, exhaust- 
ing and prolonged course. The advent of pulmonary 
edema in pneumonia is of very grave significance. The 
sputum takes on particular character. It becomes 
thin, watery, profuse, pink or blood-stained and is 
frothy. Dyspnea and cyanosis become extreme, the 
facial expression becomes very anxious, the pulse very 
rapid and feeble, and collapse may soon follow. 

Endocarditis. — The toxines formed during the 
course of the acute infectious fevers seem to have a 
peculiar affinity for, and to be capable of injuring, the 
cardiac tissues. In scarlet fever, rheumatic fever, ery- 
sipelas, cerebrospinal meningitis and pneumonia, cardiac 
complications are not uncommon. Endocarditis may be 
present without symptom or sign ; at other times it may 
be detected only by the physical signs. Subjective and 
objective symptoms may be present as an exaggeration 
of the fever, rapid and irregular pulse, palpitation of 
the heart, precordial discomfort, difficult breathing and 
prostration. 

Intestinal Hemorrhage. — This complication is fre- 



DETECTION OF COMPLICATIONS. 67 

quent in only one of the acute infectious fevers; 
namely, typhoid fever. In the first 137 cases of 
typhoid fever occurring in the Samaritan Hospital 
which I tabulated several years ago, I found ten cases 
of intestinal hemorrhage (7 per cent.) The bleeding 
may vary from only a slight oozing to a profuse 
hemorrhage. The appearance of the stool is not 
always a true index of the severity of the hemorrhage. 
A severe hemorrhage may take place, and yet the 
blood will not appear in the bowel movement for some 
time. Bleeding occurs most frequently during the 
third week of the disease, at which times the sloughs 
of the intestinal ulcers are separating. Intestinal 
hemorrhages usually occur insidiously, without pre- 
monitory symptoms. I have had my attention called 
to a danger signal which is said to occur previous to 
intestinal hemorrhage ; i. e., continued paleness of the 
face. I have not observed this sign in a sufficient 
number of cases to place credence on it. The usual 
symptoms of intestinal hemorrhage are rapid fall of 
temperature, cutaneous and mucous membrane pallor, 
cold extremities; small, feeble and rapid pulse, and, in 
severe cases, general collapse. It should be remem- 
bered that the blood does not always make its appear- 
ance during the stage of active hemorrhage. 

Intestinal Perforation. — Although a rare compli- 
cation, it does occur in typhoid fever. Of the 137 
cases of typhoid fever referred to in the section on 
intestinal hemorrhage, two were complicated with in- 
testinal perforation. This complication is of very 
grave significance, only a very few recovering. It is 
ushered in by sudden and very severe pain in the 



68 FEVER NURSING. 

abdomen, and the signs of collapse, fall of tempera- 
ture to a low point, and a rapid, feeble pulse. Great 
distention of the abdomen predisposes perforation. 

Nephritis is a frequent complication of the acute 
infectious fevers, especially of scarlet fever, diphtheria, 
erysipelas, cerebrospinal meningitis and influenza. In 
scarlet fever, kidney complications seem most frequent 
in the latter part of the third week. The disease 
manifests itself by a diminution in the amount of urine 
voided. The urine is of a high specific gravity, dark 
in color (it may be of a "smoky" or "briny" color) and 
contains much albumin. There is usually edema of 
the skin, appearing first in the lower eyelids, and may 
later become general. Lumbar pains, vomiting and 
signs of gastro-intestinal disorders may occur. In the 
severe cases uremic signs are apt to be manifest. 

Otitis Media, or middle-ear disease, may compli- 
cate scarlet fever, diphtheria, cerebrospinal menin- 
gitis, measles and mumps. The affection is charac- 
terized by ringing in the ears, dizziness, difficulty of 
hearing, pain, discharge and febrile disturbance. 

Paralysis. — Various forms of paralysis may com- 
plicate the acute fevers. In diphtheria they are not 
infrequent. Paralysis of the muscles of the palate is 
common and causes regurgitation through the nose of 
fluids and small particles of food on attempting to 
swallow. A characteristic nasal twang is produced. 
Paralysis of other muscles may occur — as the facial, 
ocular, largyneal, humeral, etc. In cerebrospinal men- 
ingitis, not only may the muscles of the eye, tongue 
and larynx be paralyzed, but even the arm or the whole 
of one side of the body. 



DETECTION OF COMPLICATIONS. 69 

Pericarditis may occur in scarlet fever, pneu- 
monia, erysipelas, rheumatism and cerebrospinal men- 
ingitis. The onset of pericarditis does not depend on 
the extent or severity of the primary disease. The 
author has reported a fatal pericarditis with effusion 
complicating a mild case of pneumonia with consoli- 
dation no larger than a silver dollar. The signs of 
pericarditis are exaggeration of the fever, precordial 
distress, cough, difficulty of breathing, palpitation and 
a rapid, weak pulse. 

Phlebitis and the formation of thrombi in the veins 
occurred in four of the 137 cases of typhoid fever 
referred to above. In one instance it formed on the 
sixty-sixth day of the disease. There is pain and ten- 
derness at the site of the phlebitis, and the vein may 
feel like a hard cord. The parts below become swollen 
and edematous. The thrombosis occurs, as a rule, in 
the left femoral vein. If the artery is involved, gan- 
grene will likely follow. 

Pleurisy in pneumonia should be considered as a 
symptom rather than a complication, for it occurs 
in all cases where the surface of the lung is involved. 
As a complication it is seen in rheumatic fever, influ- 
enza, typhoid fever, measles and scarlet fever. Signs 
of the onset of pleurisy are sharp, stabbing pain in 
the chest, especially when coughing or taking a deep 
breath, chills or chilly sensations ; suppressed, dry 
cough and dyspnea. 

Pneumonia, when complicating the infectious 
fevers, is usually of the catarrhal or bronchial type, 
and is encountered most frequently in erysipelas, influ- 
enza, measles, rheumatic fever, whooping-cough and 



70 FEVER NURSING. 

cerebrospinal meningitis. Pneumonia is a very serious 
complication, and when affecting a debilitated person 
suffering from one of the acute fevers it is very apt 
to prove fatal. This is especially the case in measles. 
The onset of this complication is accompanied by irreg- 
ular, high fever, great prostration, cough, cyanosis, 
difficult breathing, chills and a very rapid pulse. 

It may be said that when one disease complicates 
another, the course of the complicating disease is not 
only often irregular, but may be completely concealed 
by the primary disease. 



PART IL 

SPECIAL DISEASES. 
CHAPTER VII. 

TYPHOID FEVER. 

Synonyms. — Enteric Fever, Abdominal Typhus. 
Autumnal or Fall Fever. 

Etiology. — The causes of typhoid fever are divided 
into two classes — predisposing and exciting. 

The onset of an acute infectious disease depends on 
two factors, namely, the resistance of the individual 
and the virulence of the bacteria and their products. 
If the resistance of the person be lowered by exposure 
to cold and damp, to poor food, etc., then the specific 
bacteria, if they gain entrance to the body or are pres- 
ent in the body, can easily propagate because the re- 
sistance or vitality of the person is not great enough 
to stand the attack of the micro-organisms ; conse- 
quently disease ensues. On the other hand, if the 
resistance of the individual be high, that person may 
even withstand the attack of very virulent germs. 

If no germs of a certain disease are present or if 
they do not gain entrance to the individual, no matter 
how low his resistance may be he will not contract that 
disease. 

n 



7 2 FEVER NURSING. 

The onset and severity of the course of an acute in- 
fectious disease depend on the degree of resistance of 
the person and the virulence of the infective micro- 
organisms. 

The predisposing causes of typhoid fever are Fall 
season and adult life, — typhoid fever occurs but rarely 
in the very young or aged. Males and females are 
about equally susceptible. 

The exciting cause is the bacillus of Eberth and 
Koch, or the Bacillus Typhosus. This bacterium has 
great powers of resistance. The bacillus retains its 
vitality for some time even if heated to 140 F. (dry 
heat), but will not withstand the same amount of moist 
heat. It lives even in ice. 

The bacilli gain entrance to the body in many ways, 
but the principal means of ingress are by food and 
drink. Drinking water probably forms the most fre- 
quent mode of entrance. The small creeks and streams 
leading into the water supply of cities are a source of 
infection. These small streams derive their virulence 
from contamination with the excreta of infected per- 
sons. The excretions, even if thrown on the ground 
or buried some distance from the stream, are dangerous 
and may contaminate the water by percolating through 
the ground or being washed in by heavy rains or by 
the freshets in the Spring. 

Ice taken from ponds or places contaminated with 
the bacilli is dangerous. Food infected by polluted 
hands, by exposure to impure air, or by infectious ma- 
terial carried by flies and insects, is a source of the 
disease. 

Vegetables and fruits handled by unclean hands or 



TYPHOID FEVER. 73 

washed with contaminated water are another source. 
Milk derives its infective character from polluted hands, 
or from infected water used either to adulterate the 
milk or to clean the pans and cans into which the milk 
is placed. The germs may also drop in from the air 
which has been contaminated by the secretions of man 
or animal. 

Oysters are said to be a carrier of the infection. 
They derive their virulence from sewerage which is 
deposited into the water near the oyster beds. Clothing 
and bedding become contaminated by drying dejecta. 
Human beings may act as bacilli carriers, and many 
instances of such have been recorded in medical 
literature. After an attack of typhoid fever, the 
germs may be found in the bowel movements and urine 
for months, even years, and thus the individual be- 
comes a menace to public health for a prolonged time. 
Other persons who themselves have never suffered 
an attack of typhoid fever, but have been in contact 
with the patients, may retain the bacilli and impart 
the disease to others. Flies are found to be a frequent 
means of disseminating the disease. This has been 
repeatedly demonstrated to be the case, especially in 
the Hispano-American conflict, when flies would travel 
from the excretion trenches to the cook tents and 
kitchens, thus infecting the food of the troops. 

From what has been said of the cause of typhoid 
fever it will be seen that much can be done to prevent 
this disease. Only such water as is perfectly pure 
should be used for potable purposes. If there be any 
doubt, the water should be boiled well and cooled by 
placing ice around the receptacle holding the water 



74 FEVER NURSING. 

and not in the water. To prevent the spread of the 
disease everything which comes in contact with the 
patient should be thoroughly disinfected after its use. 
Windows, not only of the sick-room, but of the house, 
should be thoroughly screened. The excretions of the 
patient should be so covered that they are not access- 
ible to flies. 

The excretions from the bowels and the urine should 
be collected in vessels containing some disinfectant, as 
carbolic acid (i to 20) or bichlorid of mercury (1 to 
1000). Do not use the bichlorid of mercury in metallic 
dishes. Before throwing the excretions away they 
should be mixed well with chlorinated lime or a strong 
solution of copper sulphate, and allowed to stand for 
a short time. 

Bed clothing should be soaked in bichlorid of mer< 
cury solution or carbolic acid solution before washing. 
Gauze or handkerchiefs used to collect the nasal and 
pharyngeal secretions should be burned. A separate 
set of dishes should be used for the patient. 

Wash the perineum and surrounding skin with some 
antiseptic solution after each bowel movement. 

Clinical Symptoms. — The disease is gradual in its 
onset. The prodromal symptoms are lassitude, malaise, 
loss of appetite, headache, especially of the frontal 
type, dizziness, insomnia, slight cough, pain in the nape 
of the neck, catarrhal conditions of the nose and throat, 
nose bleed, vague pains, and often slight diarrhea. 

Temperature. — The fever rises gradually with a step- 
like curve with daily remissions of one-half to two de- 
grees, and reaches its height usually in seven to four- 
teen days. After reaching the fastigium the tempera- 



76 FEVER NURSING. 

ture remains there with but slight diurnal remissions 
for a period of about one week when it begins to de- 
cline with marked daily remissions. The temperature 
generally reaches the normal at the end of the third 
week or the beginning of the fourth week. 

A temperature of 103.5 °~ io 4-5° F. is the average in 
the second week of typhoid fever. If the fever persist 
at 105 ° F. for any length of time, it is serious. A con- 
tinued high temperature may be due to some compli- 
cation as otitis media, pneumonia, etc. A sudden fall 
in temperature may be due to intestinal hemorrhage 
or perforation of the bowels. In the decline of the 
fever a sudden rise may be due to the onset of some 
complication, to constipation, an error in diet, or mental 
emotion. 

Spleen. — The spleen as a rule is enlarged. The en- 
largement is generally perceptible at the end of the first 
week and disappears in the second or third week. A 
persistently enlarged spleen is said to be indicative of a 
relapse. 

Countenance. — The face is at first flushed and the 
eyes bright; later the patient becomes listless and the 
expression dull. 

Eruption. — This occurs at the end of the first week. 
It appears in crops lasting from one to four days. Its 
presence is especially noticeable on the front of the 
abdomen and chest as a rose red papular eruption, 
which disappears on pressure. 

Tongue. — The tongue at first is only slightly coated 
and is moist. As the disease progresses there is a tend- 
ency for the tongue to become dry, and in severe cases 
a dry tongue with numerous deep cracks is not an 



TYPHOID FEVER. 77 

uncommon occurrence. The tongue is protruded very 
slowly, due to the apathetic condition of the patient. 

Stools. — The bowel movements in over fifty per cent 
of cases are of a yellow ochre color and are called pea 
soup stools. The odor is very foul and more or less 
characteristic. 

Tympanites or distention of the abdomen occurs to 
some extent in nearly all cases of this disease. It may 
reach an alarming degree and interfere with the action 
of the heart and lungs. 

Respiratory Tract. — Bronchitis of varying degrees 
is a very frequent accompaniment of typhoid fever. 
Pneumonia may occur in the course of the disease cr 
as a complication. 

Circulatory System. — The pulse during the first week 
varies from 75 to 85 and is in proportion to the rise of 
temperature. Later in the disease the rise of tempera- 
ture is greater than the advance in the pulse rate. A 
pulse rate of 120 in the second week of typhoid fever, 
if not due to a complication, is said to be a signal of 
danger. The pulse is often dicrotic after the first stage 
of the disease. Pericarditis and endocarditis are rare 
complications of typhoid fever. 

Thrombosis of the vessels, especially those of the 
thigh, is not uncommon. Gangrene of the extremity 
may follow. 

Digestive System. — Tongue. (See above). 

Diarrhea occurs in fifty per cent of cases, and if a 
purge be given, excessive catharsis may follow. 

Vomiting is not common, but does occur in the third 
week, due to an error in diet, perforation of the bow- 
els, or local peritonitis. 



7 8 FEVER NURSING. 

Sordes of teeth and lips is an accumulation of food, 
micro-organisms and epithelia. 

Hemorrhage or perforation of the bowels may occur. 
For a description of these see the section on Detection 
of Complications. 

Musculature. — The muscles diminish in size and be- 
come flabby. Emaciation is rapid in cases associated 
with diarrhea. 

The urine is diminished in amount, is highly colored, 
specific gravity is raised, urea is diminished, and albu- 
men may be present in small quantities. In some cases 
the urine is greatly increased in amount and of a light 
color. The Ehrlich diazo reaction may be present, a 
description of which may be found in more exhaustive 
works. 

Nervous System. — Delirium occurs in a large per- 
centage of cases, and may be of the active or noisy 
type, or the low muttering form. The latter is more 
common. It occurs in the second or third week. The 
patient becomes stupid, mutters to himself, may pick 
at the bed clothes (carphologia). A twitching of the 
wrists, etc., is often present fsubsultus tendinum). 
The patient may lie with the eyes widely open and stare 
in one direction for some time (coma vigil). 

Convulsions may occur in the young. 

Other symptoms which may occur are deafness, bed 
sores, sweats, boils, jaundice, laryngitis, hypostatic 
congestion of the lungs, neuritis, nephritis, bone lesions 
and arthritis. 

Diagnosis. — This can usually be made from the 
several davs of malaise, frontal headache, slight cough, 



TYPHOID FEVER. 79 

loss of appetite, nose bleed, rose rash, and enlarged 
spleen, together with the temperature characteristics. 

Typhoid fever may be confused with acute miliary 
tuberculosis, gastro-intestinal disorders, auto-intoxica- 
tion, cerebrospinal meningitis, pneumonia, remittent 
fever, secondary syphilis, bronchitis in children, ulcer- 
ative endocarditis, influenza, trichinosis, appendicitis, 
septic processes, typhus fever, articular rheumatism, 
and abscess of the liver. 

For the Widal reaction see section on Bacteria in the 
[Addenda. 

Prognosis. — The prognosis depends greatly on 
the treatment. The institution of baths in the treat- 
ment of typhoid fever has greatly reduced the rate of 
mortality. A more or less persistent temperature of 
105 ° in the first week is grave. A pulse of 120 or 
over is serious. 

Diarrhea does not seem to have any effect on the 
prognosis unless it be exhausting. 

Marked tympanites may cause pulmonary compli- 
cations and may portend perforation of the bowels. 
Hemorrhage is weakening. Perforation is very serious. 
Severe nervous symptoms are serious. 

Care and Management. — Prophylactic measures 
are of utmost importance in combatting the spread of 
typhoid fever. The nurse being in constant attendance 
will play the chief role in preventing the propagation 
of the disease to other members of the patient's family 
or to the individuals of the community. 

The water supply, as has already been indicated, is 
the chief source of danger. All water used by the 
patient and the family should be of a known purity. 



80 FEVER NURSING. 

If it be impossible to get an absolutely pure spring 
water, then the regular drinking water may be used, 
but it must first be made danger-free. This can be 
very easily accomplished by boiling. The water should 
be boiled vigorously for fifteen minutes and then al- 
lowed to cool. 

Do not place ice in the water after it has been boiled, 
for in doing so the water is rendered liable to infection. 
The proper way of cooling the water is to place the 
pitcher or receptacle filled with water into a larger dish 
or pan, and then surround the pitcher with cracked 
ice.. In this way you prepare iced water and not ice- 
water. 

'Milk is another source of danger and unless known 
to be absolutely free from infection should be rendered 
so. Milk may be either sterilized or pasteurized. 

To sterilize milk it must be kept at the boiling point 
(212 F. or ioo° C.) for fifteen or twenty minutes. 
Sterilization of milk renders it less digestible, precipi- 
tates the albumin and partially destroys the fat emul- 
sion. 

Pasteurization is to be preferred if the milk is to be 
used within twenty-four hours. This is done by rais- 
ing the milk to a temperature of 155 F. or 68° C. for 
thirty or thirty-five minutes and then rapidly reducing 
the temperature to 50 F. or io° C. Place in the 
refrigerator, ready for use. Pasteurization destroys 
the germs but does not produce the changes in milk 
that sterilization at the boiling point does. 

We have considered the methods of preventing the 
spread of typhoid fever from outside sources ; now 
let us consider the dangers of infection from the patient 
himself. 



TYPHOID FEVER. 8l 

All secretions and excretions of a typhoid patient 
may be a source of infection, some to a greater degree 
than others. 

First, we have the secretions from the nose and 
throat. These are usually collected on handkerchiefs. 
It is better to use for this purpose pieces of old muslin 
or linen. The cloths after being used by the patient 
should be burned and not washed. Expectoration 
should be expelled into small pieces of tissue paper 
and immediately destroyed by fire. 

Clothing. — The undershirt and gowns which are 
contaminated by perspiration and possibly by urine, 
should be thoroughly soaked in ten per cent solution 
of carbolic acid before they are washed and boiled. 

The urine and feces are a most dangerous source 
of infection. The urinals and bedpans should contain 
some antiseptic, as ten per cent carbolic acid solution, 
solution of copper sulphate, chlorinated lime; if the 
vessels are not metallic, a one to five hundred solution 
of the bichlorid of mercury should be used. The anti- 
septic should be placed in the vessel before and not 
after using. Thoroughly mix the excretive matter 
with the antiseptic and allow it to stand for a while be- 
fore emptying it out. In the country and in houses 
not connected with a sewer system, the excretion 
should not be thrown into the privy vault, but into 
deep trenches, dug some distance from wells and cis- 
terns, and where the natural grade of the ground is 
away from the water supply and creeks or ponds. 
The trenches should, be three feet deep and provided 
with a cover. They should have a bottom of three 
inches of unslacked lime. The excreta should be dis- 



32 FEVER NURSING. 

infected before being emptied into the trench. Lime 
should be sprinkled in after each load of excreta. The 
trench should not be filled with excreta, but be covered 
in with lime and earth when half-filled, and another 
trench dug. 

Diet. — What should constitute the diet during the 
course of typhoid fever is a much debated question. 
Although many diverse statements have been made on 
this subject, nevertheless, according to the majority 
of physicians, milk forms the basis of diet. 

At least four ounces of milk should be given every 
two hours. If whole milk does not agree with the 
patient, it should be diluted with plain sterile water, 
limewater or Vichy. Water should be given freely, 
but it cannot take the place of milk. 

The author has found a very valuable diet during 
the acute stage of typhoid fever to be one which is 
partially based on the caloric value of foodstuffs. 
The patient is to receive an eight-ounce feeding every 
two hours from 8 a. m. to 8 p. m., and then is placed 
on a four-hour schedule until 8 the next morning. 
The diet consists of two parts — the milk mixture, and 
the carbohydrate mixture — which are to be given alter- 
nately. The milk mixture consists of six ounces of 
whole milk, into which is thoroughly beaten the white 
of one egg, and then one teaspoonful of milk sugar is 
to be added. The balance of the eight ounces is to 
consist of plain water, or equal parts of water and lime 
water. The carbohydrate mixture consists of eight 
ounces of farina gruel or cream-of-wheat gruel, made 
as directed in the recipes found in Chapter III, using 
a teaspoonful of milk sugar to each feeding. As the 



TYPHOID FEVER. 83 

disease progresses toward convalescence the whole tgg, 
instead of the white only, may be employed in the milk 
mixture. If it be considered necessary, spiritus 
frumenti or spiritus vini Gallici may be added to each 
feeding of the milk mixture. 

Other articles of diet which the author has found 
valuable, and which break the monotony, are clam 
milk, oyster milk, ice cream and junket. 

Lemonade, weak tea and coffee are allowable. Beef 
tea, beef broth, some form of predigested beef, gelatin, 
egg-albumin water and barley water may be given, 
depending on the physician's orders. For the prep- 
aration of these articles of diet see Chapter III. 

No solid food is to be given until the temperature 
has been normal for at least ten days. 

The medicinal treatment of uncomplicated cases of 
typhoid fever amounts to almost nothing. Recovery 
depends mainly on general measures and good nursing. 

Fever. — The reduction of temperature by means of 
drugs in typhoid fever is almost obsolete. The physi- 
cians of to-day depend nearly entirely on hydropathic 
measures. A nurse to be thoroughly proficient must 
know not only how to apply the different means of 
reducing fever without the aid of drugs, but must also 
know their relative value and indications. 

When the temperature is moderate (103 F.) cold 
baths need not be given. The regular daily cleansing 
bath, together with proper ventilation, light bed cloth- 
ing, and cooling drinks are all that are necessary. 

When the fever rises above 103 ° F. more vigorous 
means are demanded. Cold sponges, alcohol rubs, cold 
packs, and cold tub baths are the more common meth- 
ods. For details of these see Chapter IV. 



84 FEVER NURSING. 

The systematic use of baths has greatly reduced the 
mortality in typhoid fever. Applications of cold not 
only reduce the fever but accomplish equally if not 
more important other results, as quieting delirium, 
overcoming insomnia, steadying the pulse and heart, 
and improving respiration. 

It was said at one time that baths were contra- 
indicated in hemorrhage and perforation of the bowels. 
It has been established that hemorrhages do not contra- 
indicate the giving of cold baths. 

Plenty of water given internally also tends to lower 
the temperature by inducing sweating, thus losing 
heat by evaporation and through abundant hot urine. 
There is one important condition which necessitates 
abstention from giving baths, and that is a weak heart. 
When cold is first applied to the body the surface 
capillaries are generally contracted, the arterial tone 
is raised, and the blood accumulates in the deep organs. 
This places a sudden and extra labor on the heart and 
may cause dilatation and sudden collapse. 

The use of external cold in the form of sponges, 
packs, etc., as an antipyretic measure is usually insti- 
tuted when the temperature reaches 103 ° F. It is 
important that the temperature be not reduced lower 
than 100.5 ° F- because after the completion of the 
bath the temperature usually falls a degree or more. 
If the temperature be kept above the normal, there is 
no danger, but great care must be taken because when 
the temperature is reduced below ioo° F. it at times 
falls very rapidly and collapse may follow. 

In applying cold by any method surface reaction is 
of prime importance. In order to obtain this, constant 



TYPHOID FEVER. 85 

and somewhat vigorous friction and rubbing- are neces- 
sary. During the procedure the patient is not to be 
allowed, under any circumstances, to exert himself. 
He is to be absolutely passive, as conservation of heart 
energy is a most important object. It is very seldom 
necessary to give more than six baths in a day. The 
patient is exhausted when the baths are too frequently 
given and they become a source of harm rather than 
of benefit. The writer left word with the nurse on 
one of his typhoid cases that she should give the baths 
at such times as she thought necessary. The next 
morning the patient was in a more or less exhausted 
condition. The nurse, on being asked how many baths 
were given since the last visit, which was the day be- 
fore, replied eighteen. This accounted for the great 
weakness of the patient. 

Bed Sores. — These common occurrences are first to 
be prevented from forming ; if this be impossible, then 
measures must be adopted to induce rapid healing. 

To prevent them two objects are to be accomplished 
— removal of pressure against the parts, and hardening 
of the skin. The first is brought about by frequent 
changes in the position of the patient or by interposing 
some cushion between the parts pressed upon and the 
bed. For this purpose the rubber pneumatic ring or 
large pads of cotton may be used. 

To harden the skin, bathe the parts with alcohol or 
paint them with a mixture of aloes and glycerin. 
(Take one ounce of the tincture of aloes and heat it 
until it is evaporated to one-half ounce. While it is 
evaporating add gradually six ounces of glycerin.) A 
most efficient means is to rub the parts with a fresh 



86 FEVER NURSING. 

slice of lemon. Applications of salt and whiskey are 
good. (Salt, one dram; whiskey, eight ounces.) 

•When the sore is formed the above measures are 
useless. The sore must be kept very clean, preferably 
by syringing with peroxid of hydrogen, and then rins- 
ing with sterile water. Some ointment, as twenty-five 
per cent ichthyol ointment, should then be applied. 

The month should be kept scrupulously clean. A 
very good mouth wash is prepared as follows: Boric 
acid, one dram; juice of one lemon; glycerin, one 
ounce ; and water to make four ounces. A one to one 
thousand solution of potassium permanganate makes 
an excellent wash. 

Nausea and vomiting, although rare in typhoid 
fever, may occur. A mustard plaster placed over the 
pit of the stomach or an ice-bag on the epigastrium are 
very useful. Limewater added to the milk will be 
successful in many cases. A measure which is easily 
applied and often works well is the inhalation of vine- 
gar fumes. 

Diarrhea is very common. When the bowel move- 
ments number more than six in twenty-four hours, 
active measures must be taken to stop the diarrhea. 
Enemata of starch paste and laudanum, together with 
a mustard paste applied to the epigastrium, are very 
useful. Meat juices and broths should be discontinued 
if they are being given, as they often cause the diar- 
rhea. The diet should be reconsidered ; probably the 
patient is receiving too much milk or milk not suffi- 
ciently diluted. 

Tympanites is a common and at times a very trouble- 
some symptom. It is due to fermentation in the bow- 



TYPHOID FEVER. 87 

els, to paresis of the muscular coat of the intestines, 
or to a combination of both. If due to fermentation, 
intestinal antiseptics, such as salol, thymol, sulpho- 
carbolates, etc., and evacuation of the fermented ma- 
terial by means of laxatives or enemata are indicated. 
If due to sluggishness or paresis of the bowels, an 
intestinal tonic or stimulant, as turpentine, is indicated. 
Turpentine is the best drug we have for relieving the 
tympanites. It may be used in three ways : internally, 
about which the attending physician will give instruc- 
tions ; by rectum ; locally to the abdomen as stupes. 

Asafetida as an enema is also very useful in expell- 
ing gas. See Chapter XXVIII for instruction in pre- 
paring enemata and stupes. 

Constipation. — The bowels should move at least once 
a day. After the first week it is advisable not to use 
cathartics but to resort to enemata. Enemata of soap 
suds, glycerin and water, cotton-seed oil, or the pur- 
gative enema may be used. See Chapter on Enemata. 

Epistaxis, if it persist or be profuse, should be 
treated. Douching the nose with plain hot water, or 
hot water and vinegar, is useful. Spraying the nose 
with a one to one-thousand solution of adrenalin 
chlorid is useful. 

Delirium is best combatted by cool sponges and 
baths. Opium in the form of Dover's powder is bene- 
ficial if a sedative be necessary. 

Hemorrhage and Perforation. See Chapters V and 
VI, Part I. 

Care in Convalescence. — During this period care 
as great as, if not greater than, that during the general 
course of the disease is necessary. As convalescence 



88 FEVER NURSING. 

advances the visits of the physician become less and 
less, the responsibilities of the nurse become greater 
and greater. It is at this time that the patient regains 
that which he had lost during the run of the disease, 
as blood, fat, muscular tissue, nervous and mental 
energy. 

The dangers of convalescence are many. The pa- 
tient acquires a ravenous appetite and demands a 
greater amount of food and even makes threats as to 
what he will do if an increased amount* of diet be not 
oncoming. Great vigilance on the part of the nurse 
is necessary. 

Solid food should not be given until the temperature 
has been normal for ten days ; in the meantime the 
diet can be varied with eggs in different forms, cereals, 
jellies, gruels, toasts, etc. Perforation of the bowels 
has occurred late in convalescence due to the eating 
of a meat chop. 

A rise of temperature during convalescence may be 
due to a true relapse, which as a rule pursues a shorter 
and milder course than the general attack ; or it may 
simply be a recrudescense due to constipation, an error 
in diet, or to mental excitement. A visit from an 
unwelcome person may send the fever very high. 

The patient should at first sit up in bed for a short 
time daily, then should sit up in bed to eat his meals 
and later to read or to receive visitors. As he gains 
strength he may sit in a chair for a short time, but 
should not receive visitors during the first few seances. 
Walking about the room, first aided and later unaided, 
should be gradually undertaken. 



PARATYPHOID FEVER. 89 

Paratyphoid Fever. 

From the experience of the author, it seems proper 
that this disease be considered an entity, and deserves 
separate description. Owing to its similarity and con- 
fusion with typhoid fever, it is best described here. 
The author's recent writing * is freely employed. 

Historical. — Over 300 cases of this affection have 
been reported in literature, which have followed a 
course resembling that of typhoid fever, but in which 
the causal element was found not to be the bacillus 
typhosus. Archard, in 1896, described the first two 
cases of paratyphoid fever, and isolated a bacterium 
differing in many ways from the typhoid bacillus. In 
rapid succession, cases were reported, and the bacillus 
studied, by Widal, dishing, Jurgens and others. 

Etiology. — The bacillus paratyphosus belongs to the 
genus Typhocolon. It stands between the colon bacillus 
and the typhoid bacillus, probably in closer relationship 
to the latter. Of the members of this family, the 
bacillus coli communis and the bacillus typhosus are 
diametrically placed, with the members forming mid- 
groups, the paratyphoid bacillus closely approximating 
the bacillus typhosus, whereas the bacillus of Gaertner, 
or the bacillus of meat poisoning, which also is closely 
related, is placed nearer the bacillus coli. The bacillus 
paratyphosus differs from the bacillus of typhoid fever 
in that the former is shorter, more slender, less flagel- 
lated and more motile. It also is unlike in certain 
cultural properties. From the bacillus coli it is dis- 
tinguished by its failure to produce indol. 

* N. Y. Med. Journ., xcii, p. 809. 



90 FEVER NURSING. 

Prodromes. — The onset of this disease is generally 
of brief duration and somewhat abrupt. The patient 
who was in former good health is soon complaining 
of various muscular and so-called bone pains. Stiff- 
ness of the neck has been a very prominent symptom 
in this series of cases. Chills are not common, but 
the occurrence of chilly sensations and more or less 
profuse sweating are not infrequent. Sore throat, 
severe headache, pain in the "pit of the stomach," are 
ofttimes present. This short prodromal period of 
from three to five days' duration, contrasts markedly 
with the long-drawn, insidious onset of typhoid fever, 
with its malaise, anorexia and insomnia. 

Symptoms. — The general symptoms of the disease 
are of early advent. The patient may present an 
anxious and flushed appearance for the first few days, 
and stupidity may exist in a mild form, but in the 
writer's cases these signs soon disappeared, and the 
patients became extremely bright and placid, troubled 
not in the least with insomnia. In severe cases, great 
dulness of intellect and delirium may occur. The 
headache of the prodromal period, which is rather a 
pain (cephalalgia) than an ache, soon lessens and dis- 
appears. The alimentary symptoms are to a certain 
extent characteristic. The tongue, which in typhoid 
fever is early swollen, thickly coated and tremulous, 
and later dry and fissured, in this disease remains 
moist throughout, is of normal size and only lightly 
coated. Sordes do not tend to collect. The appetite 
is usually blunted in the early stage, but rapidly re- 
turns, even before the fever has desisted. Redness of 
the pharynx and painful swallowing, which may have 



PARATYPHOID FEVER. 



91 



been pronounced in the prodromal state, become less 
and pass away. Nausea and vomiting are of frequent 
occurrence in the early days of the disease. The in- 
testinal condition is quite typical. Although diar- 
hea does occur, it is not the rule, and constipation is 
much more frequent. In the writer's cases the evacu- 
ation of formed feces throughout the course of the 
disease was characteristic. Tympanites of great de- 



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j-||p||||iljjllllllll(j§fc -t- 


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Jl :y |ll : ^ : pl ; ^ 


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Fig. 11. — Temperature chart of a case of paratyphoid fever, showing the 
oscillations of fever. 



gree is not common, although slight abdominal dis- 
tention does occur, but, as a rule, is not troublesome. 
The spleen is usually enlarged ; even if not palpable, it 
may be revealed by percussion. The liver is found 
enlarged in great percentage of cases. Intestinal 
hemorrhage is not frequently met with. 



92 FEVER NURSING. 

The febrile manifestation is extremely character- 
istic. High fever may occur in the early stage, and 
the fastigium is rapidly reached. The diurnal remis- 
sion of temperature is a very pronounced and indicative 
sign. From the beginning of the disease the fever 
may remit daily, very often to normal. The fall of 
temperature is frequently as much as 4 or 5 F. The 
accompanying chart, which is quite typical of all the 
cases of this series, distinctly shows this oscillation of 
temperature. The fever, which in many instances is 
of shorter duration than in typhoid fever, may con- 
tinue for an extended period. In one of the writer's 
patients the febrile period lasted thirty-nine days. The 
decline may take place by crisis or lysis. 

The skin may present a roseolar eruption, which 
occasionally is typhoid-like, or more often as dark, 
blotchy lesion with tendency toward confluence. 
Sweating may be marked in the early stage. The 
pulse rate is slow, compared to the degree of fever 
present, and may take on a dicrotic quality. 

Complications of a purulent nature seem to be not 
at all uncommon, arthritis, otitis, osteomyelitis and 
parotiditis being the most frequent. Intestinal hemor- 
hage, if it occurs, is not alarming. Perforations of 
the bowels I have not seen reported in literature. 

But little can be said of the prognosis in paratyphoid 
fever, for reason of the limited number of cases re- 
ported in literature. As a rule, the course of the dis- 
ease is shorter and milder than that of typhoid fever. 
In some instances the duration of the affection has 
been twelve weeks or longer. Convalescence may be 
very tardy, and relapses are not uncommon. Compli- 



PARATYPHOID FEVER. 93 

cations are frequent. The mortality in reported cases 
has been about 3 per cent. 

Diagnosis.— The diagnosis of paratyphoid fever is 
of most import to us. The clinical course of the dis- 
ease bears a close resemblance to that of typhoid fever, 
and it may be absolutely impossible to distingusih the 
two diseases clinically. There are, however, certain 
points of dissimilarity. The abrupt onset, the short 
prodromal period, the marked diurnal remission of 
temperature, the blotchy eruption, the moist tongue and 
the bowel condition of paratyphoid fever will greatly 
aid diagnosis. The surety of diagnosis must, notwith- 
standing, rest on bacteriological methods. The re- 
peated absence of the Grueber-Widal reaction is of 
utmost importance. Gwyn has said that this reaction 
is found in 99.6 per cent, of all patients suffering from 
typhoid fever ; hence its constant nonappearance, or its 
occurrence only in low dilution ( 1 to 10 or 1 to 5), in 
a typhoid-like disease is very suggestive of paratyphoid 
fever. The rinding of a paratyphoid agglutination is 
typical and may occur in dilution as high as I to 6000. 
The most conclusive evidence, however, is the isolation 
of the bacillus from the patient's blood. 

Very few instances of necropsic examinations are 
recorded; therefore, our knowledge of the morbid 
anatomy of this affection is limited and very incom- 
plete. Intestinal lesions have been described in the 
form of slight ulceration, but the Peyer's patch and 
lymphatic changes are wanting. Splenic enlargement 
was the rule. 

Regarding treatment, there is little to be said, ex- 
cepting that it should be rational and conducted on 



94 FEVER NURSING. 

the same lines as in typhoid fever, as rest in bed, liquid 
diet, antipyretic measures and the endeavor to prevent 
the occurrence of complications, the thorough disin- 
fection of all excreta. 



CHAPTER VIII. 
SMALLPOX. 

Definition. — An acute infectious fever character- 
ized by an eruption, successively, of papules, vesicles, 
pustules, and crusts. 

Etiology. — The exciting cause of variola is un- 
known, but it is probably a micro-organism of some 
type. All ages are liable to the disease. Negroes and 
dark-skinned people are especially susceptible. 

Smallpox is the most contagious of all diseases. It 
spreads widely, and as a rule attacks all exposed per- 
sons unless protected by vaccination, previous attack, 
or by natural immunity. 

The contagion exists in the breath, secretions, and in 
the dry scales. The disease may be transmitted from 
dead bodies. 

Symptoms. — Prodromal symptoms are not com- 
mon. The disease usually begins suddenly and with 
severe symptoms. Three or four days of general ma- 
laise may precede the invasion. 

The symptoms are severe chill, intense headache, 
excruciating pains in the back and limbs, vomiting, 
fever, loss of appetite, and at times, convulsions. 

In many cases there is an initial rash which may 
resemble the rash of measles or scarlet fever. 

95 



96 fever nursing. 

The fever begins abruptly high and gradually lowers 
until the fourth day or such time as the eruption makes 
its appearance, when the temperature is normal or 
nearly so. This is a period of great importance as the 
patient who formerly had severe pains, high fever, 
and was generally ill is now free from fever and pain, 
and may consider himself well and thus expose others 
to the disease. This period lasts for only a few days, 
until the eruption assumes the pustular type when the 
temperature goes up to 104 to 105 F. and the patient 
becomes desperately ill. 

The eruption begins from three to five days after 
the invasion. The first manifestation consists of pap- 
ules especially on the forehead, neck, and wrists. The 
papules will roll under the finger as though they were 
small shot in the skin. This is very characteristic. 
In two or three days the papules are transformed into 
vesicles. These contain clear serum and are multi- 
locular; that is, they are composed of several pockets 
and if pressed with the finger the serum will only par- 
tially escape as some of the pockets are still intact. 
These vesicles become umbilicated, as though the top 
were being drawn in by a string, a small depression 
being formed on the summit of the vesicle. In two 
more days or on about the eighth day, the vesicles 
become filled with cloudy material of a purulent char- 
acter. The eruption has then reached the pustule 
stage. With the formation of the pustules the tem- 
perature becomes high, 105 ° F. The pustules begin to 
dry in a few days and the crusts are formed. 

During the course of the disease the pulse becomes 



SMALLPOX. 97 

rapid and feeble and delirium of a severe type may 
develop; prostration is pronounced. 

Varieties. — Confluent smallpox is very severe. 
This type is characterized by very grave symptoms, 
and an eruption similar to that described above; but 
the papules, etc., are very close and thickly set, and 
accompanied by great swelling of the parts. Superfi- 
cial abscesses are common. The prognosis is grave. 

The hemorrhagic type is the most severe form. 
Hemorrhages occur in the skin around the vesicles 
and into the pustules. Death, as a rule, follows speed- 
ily. 

Varioloid is a form of variola modified by vaccina- 
tion. The symptoms are mild. The eruption passes 
rapidly through the different stages. There is no 
secondary fever. 

Complications are laryngitis, edema of the glottis, 
bronchopneumonia, gangrene of the skin, abscesses, 
and pock marks. 

Prognosis. — In the unvaccinated the mortality 
varies from twenty-five to fifty-five per cent, and in 
the vaccinated from five-tenths to two per cent. 

Diagnosis from Chicken-Pox. — The invasion is 
not as severe in chicken-pox. The eruption of small- 
pox passes through successive stages, but is, during 
the vesicular stage, entirely composed of vesicles and 
there are no papules nor pustules. The papules in 
chicken-pox do not have the shotty feel. The vesicles 
are not umbilicated or multilocular. In chicken-pox 
the eruption comes in crops, and at the same time 
papules, vesicles, and crusts may be discovered. The 
formation of pustules is not common in chicken-pox. 
7 



98 FEVER NURSING. 

Care and Management. — The care and manage- 
ment of a case of smallpox does not differ much from 
that of any other contagious disease. A most import- 
ant part of the care is the prophylaxis, which consists 
chiefly in vaccination. 

"Before the discovery of vaccination by Jenner, small- 
pox was a most horrible destructive agent to human 
life. It is estimated that in Great Britain alone over 
30,000 deaths were due to this disease every year. 

Vaccination produces in human beings an immunity 
toward smallpox, which though it is not always abso- 
lute, is very highly protective. The disease itself does 
not entirely protect the patient from future attacks. 
There are many cases on record of a second attack of 
the disease, and even a seventh recurrence is reported. 

There has been much discussion over the protective 
power of vaccination. Some members of the medical 
profession have gone so far as to state that vaccination 
is not only not beneficial, but is harmful. If we could 
protect persons from attacks of other diseases as abso- 
lutely as we protect them from smallpox by means of 
vaccination there would be but little need of physicians 
and nurses. According to Dr. Stark, of England, of 
6000 persons innoculated with smallpox virus after a 
previous vaccination, not a single one contracted the 
disease. 

It has been said that vaccination may introduce 
into the patient various diseases as syphilis, tubercu- 
losis, erysipelas, etc. It is true that a decade ago or 
more, when humanized vaccines and impure bovine 
vaccines were used, these diseases may have been some 
few times transmitted, but today with improved and 



SMALLPOX. 



99 



pure vaccines this is an impossibility. The only source 
of danger is the introduction of pathogenic microor- 
ganisms by means of the instruments, dressings or 
hands of the attendants ; but this is a possibility in 
the case of any wound and can be entirely eliminated 
by heeding the principles of asepsis and antisepsis. 

All children should be vaccinated during the first 
year of life. Revaccination should be performed at 
the fourteenth year. Physicians and nurses should be 
vaccinated whenever an epidemic of smallpox is im- 
pending, regardless of the length of the interval since 
the previous vaccination. 

Method of Vaccination. — The cuticle is removed by 
means of a few scratches of a sharp, sterile sewing 
needle. The object is not to draw blood, but simply to 
produce an oozing of serum. The vaccine is placed 
on this excoriated area and is slightly "worked in" 
with the needle. 

The most common place for vaccination is at the 
site of insertion of the deltoid muscle in the upper and 
anterior part of the arm. In right-handed persons 
use the left arm. The female sex, especially those of 
the upper class, prefer to have it on the thigh for 
obvious reasons. 

Signs of Vaccination. — For the first three days noth- 
ing is noticed as a rule. On the fourth day there may 
be slight redness around the site of vaccination and 
also some itching. A small papule may now be seen. 
By the seventh day this papule or pimple has become 
a vesicle or small blister filled with a clear liquid. A 
red zone forms around this vesicle and may be very 
extensive. Usually about the tenth or twelfth day 



IOO FEVER NURSING. 

the liquid oozes out of the vesicles and a scab is formed 
which may adhere to the skin for several weeks. After 
the scab or crust falls off a reddened depression or 
pit remains which becomes white in time. 

In some individuals there is no discomfort of any 
kind and they would entirely forget they were 
vaccinated except for the occasional brushing- of 
the affected arm against some resisting surface. 
On the other hand, some persons become pro- 
foundly ill for a short time, due to the constitu- 
tional effects of the vaccine. On the third or fourth 
day fever may begin and persist for four or five days. 
The appetite is lost, headache and malaise are common, 
and children may become restless at night. Often the 
axillary or inguinal glands enlarge, depending on the 
site of the vaccination. Suppuration, if it occur, is 
due to some fault in technic. The arm or thigh where 
vaccination is to take place should be thoroughly 
cleansed with soap and water and some antiseptic solu- 
tion, and finally rinsed with sterile water. The needle 
and dressing should be perfectly sterile. 

Sufficient has been said on the subject of vaccination. 
We will now consider the general management of a 
case of smallpox. 

Isolation is of utmost importance and will probably 
be secured by the Health Board of the community. 

The patient should be placed in bed in a well-venti- 
lated room. Light is to be restricted as much as pos- 
sible. The bed clothing should be light. 

Fever should be combatted as in other febrile dis- 
orders (See Chapter IV). 



SMALLPOX. IOI 

The diet should be liquid and nutritious, consisting 
principally of milk, broths, gruels, etc. Water should 
be freely given. 

For the intense pain in the back and limbs, which 
is so common in the beginning of the disease, nothing 
can be done except giving anodynes, or the application 
of ice or hot-water bags. Plasters and poultices should 
not be used as they increase the irritation of the skin. 

The pulse should be carefully watched so that stim- 
ulation can be instituted as soon as it may be necessary. 

General indications should be met as they arise. 

Pitting. — There is one sign which demands special 
consideration, and that is how to treat the eruption so 
as to leave the least amount of pitting. A great many 
methods have been described to prevent the pitting in 
smallpox. In some instances they do good, whereas 
in other cases pitting results regardless of the greatest 
care taken to prevent it. 

The room should be darkened. It is advised to per- 
mit only red light to strike the patient. This can be 
accomplished by having red curtains on the windows, 
red lamp shades and even red wall paper and hangings. 

Probably the best method to prevent pitting is to 
keep the parts constantly moist by covering them with 
clothes moistened with a dilute solution of carbolic 
acid or bichlorid of mercury. A very satisfactory way 
is to anoint the parts with a one to one hundred oily 
solution of carbolic acid, or carbolated vaseline of 
the same strength. Touching the base of each rup- 
tured vesicle with a stick of nitrate of silver has been 
advocated. 



102 FEVER NURSING. 

Keeping the crusts well soaked with vaselin is of 
prime importance. Whenever carbolic acid is used as 
a local application, careful watch of the urine should 
be kept, in order to detect the signs of poisoning from 
absorption (See Chapter XXVI). 

Warm baths should be given to facilitate the sepa- 
ration of the scabs. 



CHAPTER IX. 

SCARLET FEVER. 

Etiology. — The specific cause of scarlet fever is 
at present unknown, although many investigators have 
at various times heralded their supposed success of 
finding the micro-organism. 

The disease generally occurs in epidemic form, but 
does from time to time occur sporadically. The epi- 
demics of scarlet fever are more common in the Fall 
and Winter. 

Scarlet fever is very contagious but not as much so 
as measles. A great many children escape the disease 
even when in the midst of a severe epidemic. Prob- 
ably the most dangerous time for its spread is during 
the disquamation. 

Scarlet fever is primarily a child's disease, and rarely 
attacks adults. The most common period is between 
the ages of six and sixteen years. The greatest mor- 
tality is in cases under six years. Severe and com- 
plicated attacks may arise from contact with very mild 
cases, and the mild cases may be followed by very 
grave complications. 

The mortality varies from three to thirty per cent, 
depending on the severity of the epidemic. The dan- 
gers of contagion lie in the secretions from the nose 
and mouth, in the discharges from the ear, in the urine 

103 



io4 



FEVER NURSING. 



and feces, in the exhaled air, and in the desquamating 
skin. The disease can be carried in the clothing, and 
in this way a third person infected. 

Incubation period is from twenty-four hours to four- 
teen days. 

Symptoms. — The onset of scarlet fever as a rule 
is abrupt. A child who was previously well will sud- 



DATE 








































lOfl 
107 

106 
105 

104 


M 


E 


m|e 


M 


E 


ME 


m!e 


ME 


ME 


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ME 


M 


E 


ME 


ME 


M 


E 


M 


E 


M 


E 


M 


E 


ME 


ME 


108 
107 
106 

105 
104 


103 
102 
101 
100 

99 
93 
97 














































=j= 


103 
102 

101 

ICO 
99 

9d 










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| 1 \ 4 — i — 4 — I— 






V 



Fig. is. — Temperature chart of scarlet fever. 

denly vomit without cause. This causeless vomiting 
is a very important diagnostic point. The child, if old 
enough, may complain of an intense headache; the 
temperature suddenly becomes high, and the pulse 
very rapid. Soreness of the throat and difficulty in 
swallowing are common. 

The mucous membrane of the mouth and pharynx 
may be fiery red. These symptoms just enumerated 
are the signs that usually appear in the first twenty- 
four hours of the disease. 

During the second day the eruption begins. The 
rash consists of a scarlet, punctate eruption, becoming 



SCARLET FEVER. 105 

diffuse and stippled. It begins below a line extending 
from the chin to the lower border of the ear and soon 
involves the whole body. The area around the nose 
and mouth usually escapes, leaving here a pale area 
which is more or less characteristic. 

When the eruption is well out, if the hand be firmly 
pressed on the back or front of the patient's chest, a 
pale outline of the hand will remain for some little 
time, due to a partial paresis of the vessel walls. 

During the second day another important sign known 
as the strawberry tongue occurs. The tongue is first 
evenly coated and then the papillae become greatly 
enlarged and protrude, the tongue reddens some and 
thus the characteristic state of the tongue is attained. 

On the fourth day the eruption begins to fade in 
the order of its occurrence. 

By the seventh day desquamation begins. The skin 
may be shed in scales or in sheets or casts. At times a 
perfect mold of the hand, like a glove, may be cast off. 

The fever reaches a great height suddenly, rising to 
105 ° F. or 106 F. When the eruption makes its ap- 
pearance the temperature begins to fall in a step-like 
series and generally reaches the normal at the end of 
a week. 

The catarrhal symptoms are slight or entirely absent, 
thus differing from measles. In young children con- 
vulsions often usher in the attack. The skin is dry 
and burning, the eyes are clear, the urine is scanty and 
contains some albumen. 

Complications and Sequelae. — The complications 
of scarlet fever may be numerous and severe. 



106 FEVER NURSING. 

Pseudomembranous pharyngitis is not uncommon. 
There forms on the mucous membrane of the pharynx 
a false membrane, resembling to a degree that found 
in diphtheria. It is due to the streptococcus and is dif- 
ferentiated only by a bacteriologic examination. The 
fauces and tonsils are greatly swollen, as are also the 
glands of the neck. It is in these cases that middle- 
ear disease is very liable, being due to infection through 
the Eustachian tubes. 

Malignant, bloody, or black scarlet fever is a most 
grave condition. In this form there are hemorrhages 
into the skin. The exuded blood becomes dark, and 
from this it derives its popular name. 

Otitis media is common and serious. It is due, as 
said above, to infection through the Eustachian tubes. 
It is a most common cause of deafness in children. 
The mastoid cells may become involved, and later men- 
ingitis and brain abscesses develop. 

Cervical Adenitis. — The cervical glands enlarge to a 
minor degree in a large percentage of cases. In severe 
cases they may break down and slough, leaving large 
and indolent ulcers. At times an artery may be eroded 
when the slough is cast off, which may result in fatal 
hemorrhage. 

Endocarditis is a not uncommon complication of 
scarlet fever. A patient who has struggled with diffi- 
culty to overcome the ravishes of a prolonged and 
severe attack of the disease, may live only to be trou- 
bled through the remainder of life with a much weak- 
ened heart. 

Nephritis, although a complication, is really a se- 



SCARLET FEVER. I07 

quelse and comes on after the general course of the 
disease. A child who is well advanced in convales- 
cence may be exposed to drafts of cold air and develop 
nephritis. 

It is an old and very proper saying : "In scarlet fever 
look out for the kidneys around the twenty-first day." 
Nephritis of a very severe type may follow a very mild 
attack of scarlet fever. 

The urine, which hitherto has been of a fair amount 
and contained only traces of albumen, now becomes 
very scanty, of a very dark color, and is loaded with 
albumen. It may be smoky or like beef brine, due to 
the presence of blood. The face and lower eyelids may 
become puffy and later a general edema may follow. 
There are gastric disturbances, and vomiting is com- 
mon. Headache and pains in the back may be present. 
The disease may only be mild or may progress and 
signs of uremia develop. 

The number of cases of nephritis following scarlet 
fever may be greatly lessened by careful nursing. Do 
not allow the child to leave its bed until directed by 
the attending physician. The child may have had a 
most mild attack and the parents may think it unnec- 
essary to keep the child in bed, or the child may be 
restless and desirous of getting up in a chair, but be 
careful, for it is in these cases that the most malignant 
form of kidney disease may occur. Be careful about 
exposing the child to drafts. 

Other important complications which may occur are 
pleurisy, pneumonia, chorea, rheumatism, and peri- 
carditis. 

Before discussing the treatment and care of the 



108 FEVER NURSING. 

patient I wish to call attention again to the seven car- 
dinal signs. During the first day we have: Sudden 
causeless vomiting, severe headache, sore throat, high 
fever, convulsions in the very young. 

Second day: diffuse scarlet punctate rash, straw- 
berry tongue. 

Care and Management. — How often do we hear 
the expressions, "I have had a discharge from the ear 
ever since my illness with scarlet fever ;" or "my kid- 
neys have been weak;" or "I am unable to work or 
exert myself as other people do because my heart was 
affected by scarlatina years ago." These are very com- 
mon experiences, and are very sad ones because they 
could have been avoided in many cases if proper care 
and nursing were instituted during the attack of scarlet 
fever. 

As in all contagious diseases isolation is absolutely 
necessary. The patient and her immediate attendants 
should be placed in a suite of rooms farthermost from 
the general rooms of the rest of the household. No- 
body except the medical attendants should be allowed 
admission to the sickrooms. All the unnecessary fur- 
niture, hangings, and picture frames should be re- 
moved from the room. A separate set of eating uten- 
sils should be used. If there are any public-library 
or school books in the house, they should not be re- 
turned until after disinfection. 

The patient should be placed in bed and covered 
with light bed clothing. Ventilate the rooms well. Do 
not be afraid of air. Other children of the family 
should not be allowed to go to school or mingle with 
outside children. It is better not to remove them to 



SCARLET FEVER. IO9 

another house as it is probably too late to be of good. 
They should not come in contact with attendants of the 
patient or any clothing from the sickroom. A daily 
walk in the open air is a necessity. Keep careful watch 
of them so in case they have become infected, treatment 
may at once be instituted. Arrangements must be 
made to keep the patient in bed at least three weeks. 

Diet. — As in all febrile disturbances the appetite is 
impaired and the digestive functions are below par; 
therefore, it is necessary to provide food which is 
easily digested and does not require much work on the 
part of the digestive organs. The kidneys are very 
easily disturbed in this disease, so that food which is 
irritating to the kidneys, or throws extra labor upon 
them, should be eliminated from the diet. We know 
that meats, especially the red meats, do cause increased 
renal effort. 

The requirements are that the food should be bland, 
liquid, or at least very soft and highly nutritious. 
Milk will meet all these requirements and should form 
the basis of the diet. It may be diluted with water, 
limewater, barley water, or a carbonated water. 

Water should be freely given. Lemonade is allow- 
able. A very pleasant beverage is prepared by adding 
a teaspoonful of cream of tartar to a quart of boiling 
water, the juice of a lemon, and sugar to taste. Serve 
cool. 

A daily tepid or cool bath is of service and is re- 
freshing. Should the temperature range high the bath 
may be made cooler and repeated several times during 
the day. 

The mouth, nose, and throat should receive daily 



110 FEVER NURSING. 

attention. They may be sprayed, swabbed, or douched 
with some mild antiseptic as a two per cent solution 
of boric acid, a one to sixteen solution of hydrogen 
peroxid, a one to two thousand solution of potassium 
permanganate, or one of the many alkaline antiseptics 
prepared by the reputable drug houses of this country. 

For pain in the throat nothing is more serviceable 
than the external application to the neck of an ice-bag. 
If objections are made to cold, then hot water may be 
applied. In older children the sucking of small pieces 
of ice is very agreeable and beneficial. 

Headache is best relieved by the application of an 
ice-bag, or rubbing the head with some evaporating 
solution, as alcohol or a two per cent solution of men- 
thol in alcohol. 

Sleeplessness and delirium are best combatted by 
cool baths and an ice-bag to the head. 

Ear complications are not infrequent and are very 
serious. If the patient complain of earache, or a slight 
discharge is seen coming from the external auditory 
meatus, call the physician's attention to it at once. 

For earache nothing is better than the application 
of heat. This is best accomplished by filling a common 
rubber fountain bag with water at a temperature of 
105 ° F. Raising the bag just above the level of the 
ear, allow the warm water very gently to enter the 
external auditory canal. 

When a discharge is present the ear may require 
douching. This is done in the same way, except with 
some antiseptic solution instead of water. A one per 
cent solution of boric acid or a two per cent solution 
of carbolic acid mav be used. 



SCARLET FEVER. Ill 

Kidney Complications. — The main question is how 
to prevent the renal complications. In some instances 
they cannot be prevented, no matter what is done. If 
the following suggestions are heeded the danger will 
be reduced to a minimum : 

Keep the patient in bed for a sufficient length of 
time ; at least three weeks. 

Prevent the patient from exposure to cold. 

Give water freely. 

Be careful in regard to diet. Permit no meat, broths 
or gruels. 

When nephritis makes its appearance, the bowels 
must be kept freely open with saline laxatives. The 
diet must be entirely milk. Water should be given 
in abundance. The object is to relieve the kidneys 
of part of their work. Sweating is to be encouraged 
by hot packs and baths. Hot normal saline enemata 
are very useful. Hypodermoclysis of normal saline 
solution may be given in the more severe cases. 

Heart Weakness. — The toxins of scarlet fever seem 
to have a peculiar affinity for the heart structures, and 
may result seriously. If the pulse become rapid, irreg- 
ular, or altered in rhythm, the medical attendant's no- 
tice should be called to it. Prevent as much physical 
exertion on the part of the patient as possible. 

When desquamation begins the body should be an- 
ointed with some oily preparation, as olive oil, lard oil, 
vaselin, lanolin, or glycerite of starch. This will ren- 
der desquamation more rapid and will prevent the dif- 
fusion of the scales. Before anointing the skin with oil 
or vaseline, it should be washed with warm soapsuds. 
All pieces of scaly skin should be immediately burned 
when removed. 



H2 FEVER NURSING. 

Quarantine. — This is a much debated subject. No 
length of time can be given, but it can generally be 
said that quarantine must be enforced until desquama- 
tion or scaling has completely ceased. If scaling h?.s 
ended and there is still a discharge from the nose, 
throat, or ear, danger is still present. 

After the patient has recovered it is necessary to 
prepare the room for occupancy by the household. 
This is best accomplished by fumigation or disinfec- 
tion. Foremost of all disinfectants at the present time 
is formaldehyd gas. Leave all the patient's and 
nurse's clothing in the room. Loosen the bed clothing 
and hang it about the room on chairs. Close all the 
windows and calk their loose joints and also the crev- 
ices about all doors. Open the drawers of all furniture 
in the room. Stand books on their ends and separate 
the pages. With a whisk broom immersed in water, 
or a small sprinkler, dampen slightly the carpets and 
clothing in the room. Everything is now ready for 
the disinfection. 

Formaldehyd gas is set free in three different ways : 
By heating wood alcohol; by heating the solid for- 
maldehyd ; and by heating formalin, which is a forty 
per cent solution of formaldehyd. Apparatus for gen- 
erating the gas may be purchased for a moderate sum, 
or an ordinary alcohol lamp placed under a tin vessel 
containing formaldehyd or formalin may be used. 
Henry V. Walker, of Brooklyn, has devised a very 
simple and effective method of generating the gas, 
devoid of all danger. 

To six ounces of formalin add two ounces of com- 
mercial sulphuric acid, and mix this with one pound of 



SCARLET FEVER. H3 

unslaked lime. This amount is sufficient for one thou- 
sand cubic feet capacity. If the room be larger than 
this, use larger quantities of the chemicals. This meth- 
od has the advantage of cheapness, freedom from fire, 
and does not require any special apparatus. It is very 
rapid and efficient. 

After placing the mixture in the room to be fumi- 
gated close the door tightly and allow the room to 
remain closed for twenty-four hours; then open all 
the windows to free it from odor. The room is now 
ready for occupancy. 

Precautions. — Certain precautions are necessary to 
prevent the nurse from contracting the disease, es- 
pecially if she has never had it. The nurse should be 
out of doors as much as possible when off duty. Keep 
the sick room thoroughly ventilated ; a draft is of great 
harm to the patient, but ventilation is not only not 
harmful, but necessary. 

The nurse should change her clothing frequently ; 
and also the bed clothing. 

Keep the mouth, nose, and throat clean by means of 
gargle and sprays. 

Keep all the exposed parts of the body in as clean 
a condition as possible. 

All secretions and excretions of the patient should 
be carefully collected and thoroughly disinfected. 

A separate set of eating utensils should be used for 
the patient. 
8 



CHAPTER X. 

MEASLES. 

Measles ranks next to smallpox in degree of con- 
tagiousness. When measles once enters a community 
it affects almost all unprotected children. 

Measles is an acute, infectious fever, characterized 
by coryza at the onset, followed by a peculiar blotchy 
eruption. 

Etiology. — As in the case of scarlet fever the ex- 
citing cause is unknown at the present. As said above, 
measles is intensely contagious, and the contagium is 
present in the exhaled breath and all excretions. It 
may be carried in the clothes to a third person. 

Its occurrence may be endemic or epidemic. One 
attack usually protects from subsequent ones, but many 
recurrences in the same person are known. Unpro- 
tected adults are liable to infection. 

Symptoms. — The incubation period of measles 
varies from seven to fourteen days. The disease be- 
gins in a very characteristic way and differs much 
from the onset of other contagious diseases. It is 
ushered in by a feverish cold, the eyes are watery, the 
conjunctivae are injected, and it is painful for the 
patient to look at a bright light. The nose "runs" as 
114 



MEASLES. 



115 



in a severe "cold in the head." There is a general 
malaise, loss of appetite, feverishness, chilly sensations, 
sneezing, and coughing. 

The throat is red and blotchy. On the buccal mucous 
membrane there appears a very characteristic and pa- 
thognomonic sign known as Koplik's sign. On the 
mucous membrane of the mouth, especially opposite 
the last molar teeth, there are small, bluish-white spots 
having a red base. These are formed many hours 
before the appearance of the skin eruption and are a 
great aid in diagnosis. 



OATt 










































M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 




103 
107 
106 




































































1 






109 
107 
106 
105 
104 
103 
102 
101 
100 
99 
98 
97 














105 
104 
103 
102 

101 
100 
99 
93 
97 





































































































































































































Fig. i3» — Temperature chart of measles. 

The fever for the first three or four days rises grad- 
ually to about 102 F. and then as the eruption appears 
the temperature climbs to its height, where it remains 
until the eruption is complete. It falls by crisis. 

The eruption, as a rule, makes its appearance on the 
fourth day, occurring first on the forehead, neck, be- 
hind the ears, and around the nose, and then gradually 



Il6 FEVER NURSING. 

spreading over the body. The rash begins with small, 
red papules, more or less discrete ; many of the pap- 
ules are arranged in crescentic outline, which is very 
characteristic. 

As the disease progresses the eruption takes on a 
blotchy appearance of a bluish-red hue. The face is 
swollen and has the appearance of being "boiled." The 
papules and blotches are slightly elevated. At times 
there are hemorrhages into the skin, producing what 
is known as black measles. 

Desquamation occurs usually at the end of the first 
week. It is fine and branny. The cervical glands are 
slightly enlarged, the tongue is coated, and the lips 
are dry. 

Complications. — The complications of measles are 
more serious than the disease. 

Bronchopneumonia is not an uncommon occurrence 
during measles and is very grave. If during the course 
of measles the child have a convulsion, a developing 
pneumonia may be looked for in the majority of cases, 
as a convulsion often ushers in the pulmonary com- 
plication. 

Laryngitis is common. 

Otitis media is common during convalescence. 

Cancrum oris or gangrene of the cheek occurs in 
not a few cases. It is also known as noma. 

Sequelae.— Tuberculosis follows measles very fre- 
quently and on this account careful watching and nurs- 
ing must extend far into convalescence in susceptible 
cases. 



MEASLES. 



117 



Prognosis. — The mortality of measles, per se, is 
small but the large death rate in some places is due to 
the complications, especially those of the lungs. 

Care and Management. — A patient ill with mea- 
sles of slight severity needs but little medication. He 
should be isolated as soon as the character of the dis- 
ease is known. The same precaution should be taken 
with other children in the house as in scarlet fever. It 
must be remembered that measles is more contagious 
than is scarlatina. 

The room is to be well ventilated and airy, with an 
even temperature of about 65 ° F. As the eyes are 
very sensitive to the glare of light, the room must be 
darkened or the eyes shielded, and the curtains drawn 
and the position of the bed corrected. The eye dis- 
orders seen so often in measles may be greatly lessened 
if there be instilled into each eye six to eight times 
daily a few drops of warm boracic acid solution of 
about 3 per cent, strength. 

The diet should be liquid, light, and very nutritious, 
consisting principally of milk. Water may be freely 
given. 

The usual daily bath with tepid water is to be given. 
If the fever be high or restlessness prominent, a cool 
sponge will be found beneficial. The nose, throat and 
mouth should be cared for as in scarlet fever. 

If there be a dry, troublesome cough, it may be 
greatly relieved by allowing steam to freely escape 
into the room. It is well to have the steam medicated 
with turpentine, creosote or oil of eucalyptus. Fill an 
ordinary tea kettle nearly full of water and to it add 



IlS FEVER NURSING. 

a dram of either of the above drugs. Boil the mixture 
and allow the vapors to escape into the room. 

Pneumonia is a frequent complication of measles. 
To avoid it, care must be taken that the patient be not 
exposed to cold or draughts. 

Quarantine should last at least three weeks. The 
bed clothing, gowns, and the room should be disin- 
fected after recovery of the patient, as described under 
scarlet fever. 



CHAPTER XL 
GERMAN MEASLES. 

This disease, although hardly ever requiring the care 
of a trained nurse, is discussed because of the liability 
of its confusion with measles and scarlet fever. 

Synonyms. — Rubella, hybrid scarlet fever, French 
measles, epidemic roseola, and rotheln. 

Etiology. — The exciting cause of rubella is un- 
known. It is contagious and the epidemics may be 
widespread and travel rapidly. In small towns it has 
been known to have entered every household. 

It was supposed to be akin to measles and scarlet 
fever, but a previous attack of either of these diseases 
will not protect the individual from rubella; neither 
will an attack of German measles protect from invasion 
of measles or scarlet fever. 

Symptoms. — The course of German measles can 
readily be divided into four parts, namely, incubation, 
invasion, eruption, desquamation. 

The incubation period varies from ten to sixteen 
days. 

The invasion is, as a rule, gradual and the symptoms 
are mild, although the patient may be very ill. 

The disease usually begins with malaise, headache, 
pharyngitis, and rarely with coryza and conjunctival 
disorders. There may be nausea, vomiting, pains in 

119 



120 FEVER NURSING. 

the back and legs. The cervical glands are usually 
enlarged. This last sign is the most characteristic 
symptom of German measles. 

The eruption usually begins within twenty-four or 
forty-eight hours after the infection. It makes its 
appearance first on the face and then spreads rapidly 
over the whole body. This may be complete in twenty- 
four hours and is very characteristic. The rash is 
more pronounced on the flexor surfaces of the limbs. 
The eruption, which may resemble that of scarlet fever 
or measles, lasts two or three days and then fades in 
the order of its appearance. 

The scarlatinal form is often mistaken for scarlet 
fever. The rash is of a bright red, but is very uniform 
and smooth, and stippling, so prominent in scarlet 
fever, is absent. The sore throat is of a mild type, as 
is also the fever. 

The measly form is often mistaken for measles. The 
rash is of a bright red color but the regular crescentic 
arrangement, so characteristic of measles, is lacking. 

Desquamation is slight and branny. 

Diagnosis. — The diagnosis of rubella is made from 
its mild symptoms, slight fever, the enlargement of 
the cervical glands, and the rapid appearance and dis- 
appearance of the rash. 

Prognosis is good. At times, however, the dis- 
ease takes a very severe course. 

Complications of rubella are few. The enlarged 
glands may soften and become abscesses. Pneumonia, 
nephritis, and intestinal disorders may occur. 

Management. — Rest in bed and quietness for at 
least one week are essential. Confinement to the bed 



GERMAN MEASLES. 121 

may be difficult to enforce on account of the mildness 
of the disease. 

Cold or hot applications, preferably the former, to 
the neck are useful. The patient should be quaran- 
tined for at least three weeks. 



CHAPTER XII. 

MUMPS. 

Synonyms. — Epidemic parotiditis, parotiditis. 

Definition. — An acute infectious disease, charac- 
terized by inflammation of one of the salivary glands, 
especially the parotid gland. 

Etiology. — The exciting cause of the disease is 
unknown, although certain French authorities claim 
that a coccus is the specific cause. 

The disease is contagious. Children under one year 
are rarely attacked. 

The incubation period is from fifteen to twenty-one 
days. 

Symptoms. — The disease begins with several days 
of malaise, headache, feverishness, chilliness, sweating, 
ringing in the ears, neuralgic pains, loss of appetite, 
and there may be bleeding from the nose. The swell- 
ing begins below and in front of the ear, and gradually 
extends upward and backward, so that the tumor be- 
comes shaped like a stocking. This tumor is tender 
and accompanied by more or less pain. There is a 
very tender area behind the angle of the jaw near the 
tip of the mastoid process of the temporal bone. 

It is difficult and painful to open the mouth widely. 
The saliva is usually scant and the mouth dry. An 



MUMPS. 



123 



acid introduced into the mouth causes great pain and 
discomfort, due to its stimulating the flow of the saliva. 
Swallowing is painful. The disease often affects both 
sides and may involve the testicles or ovaries. 

The course of the disease is from three to six days, 
but may be extended and complicated. 

Complications. — This disease, although generally 
of a mild character, may be seriously and gravely com- 
plicated. 

Cerebral disorders, delirium, and coma may occur. 
Suppuration of the gland, orchitis, mastitis, ovaritis, 
deafness, pneumonia, endocarditis, and pericarditis are 
among the other complications. 

Management.: — The patient should be kept in bed 
during the acute course of the disease. Liquid diet 
is about all the patient will be able to take. Mouth 
washes and gargles are useful. 

For extreme pain and tenderness hot applications are 
very good. If the child will permit, there is nothing 
more soothing than the application of an ice-bag to the 
swelling. A hot lotion of lead and opium, locally ap- 
plied, is useful. 

For orchitis, support and protection are sufficient. 

Tepid or cool sponging if the fever be troublesome. 



CHAPTER XIII. 

WHOOPING-COUGH. 

Synonyms. — Pertussis, chin cough. 

Etiology. — The specific cause is unknown. The 
disease is contagious and occurs in epidemic form. 
The contagium is conveyed in the sputum and nasal 
secretions. Children, especially those with nasal dis- 
orders, are particularly liable. Unprotected adults may 
contract the disease. 

Symptoms. — The course of whooping-cough may 
be divided into three stages, each of about two weeks' 
duration, namely, stage of onset, or the catarrhal 
stage; secondly, the convulsive or whooping stage; 
and lastly the stage of decline, or convalescence. 

The catarrhal stage is characterized by symptoms 
of a severe cold in the head and bronchitis. There is 
running of the nose, injection of the conjunctivae, slight 
fever, malaise, loss of appetite, and a dry cough. The 
cough tends to become paroxysmal in the latter part 
of this stage. The fever is moderate, very seldom 
becoming very high. 

Whooping stage is the characteristic part of the dis- 
ease. The whoop is of respiratory origin. There are 
first a series of short, jerky expiratory coughs, fol- 
lowed by a long drawn inspiration which produces 
the peculiar whoop. Several of these paroxysms may 

124 



WHOOPING-COUGH. 



"5 



occur successively, followed by the expulsion of a small 
quantity of viscid mucus. Vomiting may occur during 
or after a paroxysm. 

During the fit the veins of the face become greatly 
distended, the face congested, the eyeballs protruded 
and the conjunctivae injected. The child seems near 
its end and asphyxia impending, when air rushes into 
the lungs with a shrill sound and the paroxysm is at 
an end. From four to fifty of these fits may occur in, 
twenty-four hours. 

The Stage of Decline. — The paroxysms grow less in 
number and severity and gradually cease. The cough 
still lingers and retains to a less degree its paroxysmal 
character. Anemia of a certain grade usually develops. 
Ulcers at or near the frenum of the tongue are a fre- 
quent accompaniment and are caused by an irritation 
of the teeth during the coughing or whooping fit. 

Complications. — Bronchopneumonia is very fre- 
quent. Pleurisy, emphysema, pulmonary collapse, per- 
sistent vomiting, hemorrhages from the nose and lungs, 
meningeal hemorrhages, convulsions, and intestinal 
catarrh are among the complications of pertussis. 

Sequelae. — Pulmonary tuberculosis often follows an 
attack of whooping-cough, and care to prevent it must 
be exercised. 

Care and Management. — Whooping-cough is a 
disease of some seriousness and is made doubly so by 
the fact that it is often complicated by bronchopneu- 
monia and makes the patient particularly vulnerable 
to pulmonary tuberculosis. 

The treatment of the disease with medicines is espe- 
cially unsatisfactory. A great many drugs have been 



126 FEVER NURSING. 

advocated. Although the nurse has no power to pre- 
scribe remedies, nevertheless a partial list of the drugs 
are appended so as to emphasize the uncertainty of 
drug treatment. 

They are belladonna, antipyrin, acetanilid, phenactin, 
quinin, bromoform, bromids, chloral, opium, cannabis 
indica, amyl nitrite, cocain, chloroform, resorcin, lo- 
belia, croton chloral, ichthyol, salicylates, etc., etc. 

The patient should be kept in a large, airy r well- 
ventilated room. Plenty of fresh air is absolutely nec- 
essary. The breathing and rebreathing of the same 
infected air prolongs the course of the disease and 
increases the number of paroxysms. In summer have 
all the windows open. In whooping-cough the lungs 
and the mucous membrane of the respiratory tract are 
very sensitive to cold, and for this reason great care 
must be exercised that the patient be not exposed to 
draughts. 

The diet is to be liquid and highly nutritious. Dur- 
ing the paroxysmal stage vomiting may occur after 
each fit of whooping. In order to prevent this and to 
maintain the nourishment of the child it is best to give 
a very small amount of milk after each paroxysm, in- 
stead of larger quantities at longer intervals. 

If the disease be seen in the very early stages, it may 
be abated, shortened, or lessened in severity by spray- 
ing the mouth, nose, and pharynx with some germi- 
cidal solution. Peroxid of hydrogen gives excellent 
results when used for this purpose. Prepare a solution 
of equal parts of glycerin and peroxid of hydrogen 
and use this, well diluted, as a spray. 

If the cough be dry and troublesome, it may be 



WHOOPING-COUGH. 1 2J 

greatly relieved by saturating the air of the room with 

steam or by employing a bronchitis tent. 

A bronchitis tent may be improvised as follows : If 
the bed posts do not reach a height of three feet above 
the patient, then fasten to each corner of the bed a 
stick, — a broomstick will do, — so that the top of each 
upright stick is three feet above the patient. Place a 
sheet over these sticks so as to form a canopy or awn- 
ing above the child, and so that three sides of the bed 
are covered, thus forming a tent with a covered top 
and three sides, one side being open. Under this tent 
conduct by means of tin pipe or hose steam from a 
nearby boiling kettle of water. 

Belladonna is one of the most frequently used drugg 
in the treatment of whooping-cough, and probably ex- 
erts the greatest benefits. An excellent way of main- 
taining constantly the action of this drug is by placing 
a freshly made belladonna plaster on the back of the 
patient, preferably between the shoulder blades. The 
plaster may be renewed every five or seven days. 

During the very severe paroxysms, a few whiffs of 
chloroform are very useful. Pour a few drops of 
chloroform on the palm of the hand and allow the 
patient to inhale the vapors from your inverted hand 
as it is held near the patient's nose. 

A mustard paste to the front of the chest is useful 
in excessive and harsh coughing. 

The use of the Kilmer belt has been followed by 
good results in the author's practice. Although these 
belts are on sale, one may be improvised at home. 
Place about the child's body a band of white cotton 
flannel or woolen flannel, reaching from just below the 



128 FEVER NURSING. 

armpits to the bottom of the abdomen. This should 
be applied firmly, smoothly and tightly. By this 
scheme the number and severity of whooping par- 
oxysms may be reduced, and, as a rule, comfort is 
great and grateful. 

Whooping-cough is contagious; therefore, isolation 
of the patient is as necessary as in other communicable 
diseases. 



CHAPTER XIV. 

INFLUENZA. 

Synonyms.— La grippe, epidemic catarrh, catar- 
rhal fever. 

Definition. — An acute, infectious fever, occurring 
epidemically or pandemically, and characterized by se- 
vere general pains, great prostration, and involvement 
of the mucous membrane of the respiratory or alimen- 
tary systems and more or less pronounced nervous phe- 
nomena. 

Etiology. — The exciting cause is the bacillus of 
Pfeiffer. At times the disease appears to be conta- 
gious ; at any rate it is very infectious. The bacillus 
is found in the secretions of the nose and bronchi. 

The disease spreads with great rapidity and affects 
more people at one time than any other disease. 

In large cities it may reappear every two or three 
years. 

Infants are less susceptible than older children and 
adults, and when they do contract it they have a less 
severe form and the sequelae are less frequent. 

Symptoms. — The incubation period is from one 
to four days. The onset is abrupt, beginning with 
sensation of chilliness or even a severe chill, malaise, 
9 129 



130 FEVER NURSING. 

loss of appetite, great prostration, moderate fever, and 
severe pains in the head, back, and limbs. Herpes is 
common. 

There are four principal forms of influenza : The 
respiratory form, characterized by coryza, sneezing, 
watery discharges from the nose, injection of the con- 
junctivas, hoarseness, cough and raising of thick, puru- 
lent masses of sputum. There are also symptoms of 
severe bronchitis, the pulse becomes rapid and prostra- 
tion is out of proportion to the fever and other symp- 
toms. Laryngitis of a severe type may occur, accom- 
panied by a metallic cough, hoarseness, or even a loss 
of voice. 

The alimentary form is characterized by nausea and 
vomiting, diarrhea, abdominal pains, rise of tempera- 
ture, and in some cases jaundice. The symptoms of 
the respiratory form may also be present. 

The nervous form is often devoid of any catarrhal 
symptoms. The pains in the head, back, and limbs are 
extremely severe ; insomnia is very troublesome, the 
prostration is great, chills are common, and meningitis 
and hemiplegia may occur. 

The typhoid form is characterized by a continuous 
irregular fever. The temperature may become very 
high, the pulse be very rapid, and delirium and other 
nervous phenomena are not uncommon. This form 
simulates typhoid fever to some degree. 

Course. — In mild cases the pains are soon re- 
lieved; the temperature becomes normal in four or 
five days and convalescence ensues. In more severe 
cases the course of the disease is prolonged and the 



INFLUENZA. 13 1 

prostration continues until convalescence is far ad- 
vanced. The cough may persist for weeks. 

Sequelae. — Weakness, tiredness, and debility are fre- 
quent sequelae. Palpitation of the heart, tachycardia 
or bradycardia are frequent results. Commonly fol- 
lowing influenza are severe nervous complications of a 
functional type, such as neurasthenia, hypochondria, 
melancholia, and suicidal tendency. 

Influenza often excites into an active form many 
latent diseases. If there be a lurking area of tuber- 
culosis, it will undoubtedly become active. 

The susceptibility for all diseases is increased and 
the resistance of the individual lessened. 

Complications. — Pneumonia of the regular type 
may occur, or that form known as the grippe pneu- 
monia, due to the influenza bacillus; the import is 
grave. Pleurisy, neuritis, nephritis, meningitis, insan- 
ity, cardiac lesions, and phlebitis occur. 

Prognosis. — Influenza is slow in convalescing. It 
is a very grave disease in persons affected with tuber- 
culosis, nephritis chronica, asthma, and cardiac disease. 
In elderly individuals the prognosis is also grave. In 
the young it is not serious. In many cases the disease 
itself is entirely eradicated, but nervous disorders of 
more or less permanency remain. 

Care and Management. — Isolation is necessary 
and should be maintained. The attacks may be light 
in severity, but every person at all acquainted with 
medicine has frequently seen this disease transmitted 
to every member of a household because isolation was 
neglected. 
Rest in bed is imperative. The room should be large 



132 FEVER NURSING. 

and well ventilated. The diet should be liquid while 
fever persists, after which semiliquid articles may be 
added to the dietary. 

All excretions, especially those of the upper respira- 
tory passages, should be collected and destroyed. The 
cloths used, as handkerchiefs, are to be burned. 

If the temperature become excessive, then cool or 
cold sponges and baths should be employed. 

For the headache nothing is so useful and agreeable 
as the application of an ice-bag to the head. 

Sleeplessness may be overcome by tepid sponges, a 
hot foot bath or an ice-bag to the head. A hot drink 
will often induce sleep. 

The nose, mouth, and throat should be kept clean 
by means of sprays, douches, gargles of mild antiseptic 
solutions, as a two per cent solution of boric acid ; a 
one to one thousand potassium permanganate solution. 
or hydrogen peroxid, one to eight. 

For irritating bronchitis steam inhalations or the use 
of a bronchitis tent will be found an excellent means of 
relief. 

For the severe pains in the chest and back, the mus- 
tard paste is a most excellent agent. Turpentine and 
lard rubbed over the parts is good. A liniment com- 
posed of equal parts of alcohol, soap liniment, and weak 
ammonia water is quite efficient. 

Cardiac depression sometimes occurs very suddenly 
and immediate action is necessary on the part of the 
nurse. For this purpose use strychnin, gr. one-thirtieth 
hypodermically, and aromatic spirits of ammonia either 
alone or combined with the compound spirits of ether, 
given in dram doses. The last two should be well 
diluted with cold water before administering. 



INFLUENZA. 133 

The convalescence from influenza is very slow. 
The patient rallies very gradually from the extreme 
weakness. The general functions of the body are at 
a low ebb. After the fever has disappeared the tem- 
perature goes toward the other extreme and a subnor- 
mal condition is very frequent. The heart in many 
cases becomes quite slow. This low temperature makes 
the patient very susceptible to draughts and climatic 
disturbances. It is very important that the patient does 
not leave her bed too soon, and when permitted to do 
so, in the beginning it should be for short periods. 
A part of the day should be spent in bed until conva- 
lescence is well advanced. 

Massage is very useful in toning and repairing the 
wasted muscles. 

The diet should now be varied and highly nutritious. 
Milk and eggs should be frequently taken. 

When the patient has become fairly strong, but not 
until then, a visit to the mountains or seashore, or a 
short sea trip will be very beneficial. 



CHAPTER XV. 

EPIDEMIC CEREBROSPINAL MENINGITIS. 

Etiology. — The cause of epidemic cerebrospinal 
meningitis is the diplococcus intracellularis. Young 
children are very susceptible to the disease. It also 
breaks out in crowded places as in barracks, prisons, 
etc. Cerebrospinal meningitis is a very serious and 
often fatal disease. The membranes covering the 
brain and spinal cord are inflamed. The disease occurs 
most frequently under the age of nine or ten years. 
The germ is found in the secretions and excretions of 
the nose, throat and ears, and by this means the dis- 
ease is spread. 

Symptoms. — The onset of the disease as a rule is 
sudden. A chill as severe as the initial chill of pneu- 
monia may usher in the disease, followed by severe 
headache, vomiting, convulsions in the very young, 
pains in the back, loss of appetite, great irritability, 
somnolence. The temperature rises to 102 ° F. or 
thereabouts, the pulse is at first full and strong and 
may become very slow, the neck becomes stiff, strabis- 
mus develops, and photophobia or dread of light is not 
uncommon. In severe cases there are, in addition, 
spasms of a tonic or clonic character, opisthotonos, de- 

*34 



EPIDEMIC CEREBROSPINAL MENINGITIS. 135 

lirium, stupor, coma, and Cheyne-Stokes respiration. 
Herpes labialis is of common occurrence. 

Petechia and purpuric spots may develop in the 
skin, and it is from this that the disease acquired the 
name of spotted fever. 

Course. — There are three types of this disease. 

A mild form in which the symptoms rapidly occur 
and in three or four days disappear and a rapid 
convalescence follows. 

A simple acute form, characterized by a more or less 
irregular course of six to fifteen days' duration. The 
symptoms may be severe but complications are slight 
or absent. 

A fulminating form which begins abruptly and with 
very severe symptoms. The purpuric rash is common 
and death releases the patient in a very short time. 

Complications. — Pneumonia is not an uncommon 
accompaniment of cerebrospinal meningitis. Pleurisy 
also occurs. Pericarditis, arthritis, parotitis, and peri- 
tonitis may develop. Neuritis, paralysis, blindness, 
deafness follow complications involving nervous struc- 
tures. Hydrocephalus, otitis media and mastoiditis, 
chronic headache, and mental feebleness may result. 

Prognosis. — The mortality varies from twenty tc 
seventy-five per cent. Cases of the fulminating type 
seldom recover. 

Diagnostic Points. — Suddenness of onset, severe 
headache, projectile vomiting, bulging fontanelles, stiff 
neck, and apathy. 

Kemig's sign is of diagnostic importance. To elicit 
this sign, place the patient on his back and flex the 
thigh on the body; now, if meningitis be present, it 



136 FEVER NURSING. 

will be impossible to extend the leg on the thigh be- 
cause of the muscular contraction due to the disease. 

Lumbar Puncture. — If a long aspirating needle be 
introduced into the cavity of the spinal column between 
the third and fourth lumbar vertebrae, which space is 
on a level with the crests of the ilia, some of the spinal 
fluid* may be removed. This fluid is clear in cases of 
tubercular meningitis, but cloudy in epidemic cerebro- 
spinal meningitis. Culture for detection of the germ 
may also be made from this fluid. 

Lumbar puncture is also one method of treatment. 

Care and Management. — As far as the treatment 
of this disease by medicines is concerned, it has been 
said that the mild cases need none and the malignant 
one will not react to medication. 

The first requisite is isolation of the patient. The 
room should be large, cool, airy, and well darkened. 

The diet should consist of milk, eggs, broths, gruels, 
and predigested forms of beef. Water may be freely 
given. 

The secretions from the nose, throat and mouth 
should be carefully collected and immediately burned. 
The dishes of the patient should not be taken from 
the sick-room, and should only be used by him. 

For the headache, which is present in nearly all cases 
and is generally of a severe type, the application of the 
ice-bag to the head is the only local measure of any 
merit. Ice-bags to the head and along the spine serve 
three purposes : they relieve pain and headache ; they 
prevent excessive fever and lower the nervous phe- 
nomena, and they retard the formation of effusions. 

If the temperature be high, cold sponges or baths 



EPIDEMIC CEREBROSPINAL MENINGITIS. 137 

may be used as in typhoid fever. Warm baths at a 
temperature of 104 F. have been recommended to 
lessen the tendency to spasms and convulsions. 

Blistering agents to the nape of the neck early in 
the attack lessen the formation of meningeal effusions. 

Vomiting is best treated by thoroughly emptying the 
bowels and placing the patient on a diet of peptonized 
milk exclusively. 

Convulsions may be stopped by hot baths, and if 
very severe, by inhalations of ether or chloroform. 

Convalescence is slow as a general rule, but may 
be hastened by instituting a diet of very nutritious 
foods; by administering tonics of iron, gentian, ar- 
senic, etc., and by abundance of fresh air and sunshine. 
The sick-room and its contents should be thoroughly 
distinfected. 



CHAPTER XVI. 

ACUTE EPIDEMIC ANTERIOR 
POLIOMYELITIS. 

Synonyms. — Spinal infantile paralysis, infantile 
paralysis, epidemic poliomyelitis, acute atrophic spinal 
paralysis, amyotrophic spinal paralysis. 

Definition. — A disease occurring chiefly in chil- 
dren, and characterized by an acute febrile onset, with 
sequential flaccid motor paralysis and muscular wast- 
ing, and without prominent sensory symptoms. 

Etiology. — This disease usually occurs in children, 
especially before the fourth year. Both sexes are 
equally affected. It has followed exposure to the ele- 
ments, cold and dampness, and has been subsequent to 
traumatism. Some authorities say it mechanically 
follows a plugging or thrombosis of the anterior spinal 
artery. Others say it depends entirely on a specific 
bacterial origin. In a study of a great number of 
cases in epidemics, nothing certain as to the causative 
agent has been determined. Harbitz, as a result of 
the study of nearly 1200 cases of acute anterior polio- 
myelitis occurring in epidemic form in Norway in the 
years of 1903 to 1906, comes to the conclusion that this 
disease is due to a micro-organism, whose probable 
atrium is the digestive tract, and that the nervous 

138 



ACUTE EPIDEMIC ANTERIOR POLIOMYELITIS. 1 39 

system becomes infected either by way of the lymph- 
atic vessels or by the blood current. 

Anatomical Seat of Lesion. — The lesion of this 
affection, as its name would indicate, is situated prin- 
cipally in the gray matter of the anterior horn of the 
spinal cord, being most intense in the cervical and 
lumbar regions. The pathological findings are not en- 
tirely confined to the anterior horns, but the pia mater, 
the pons, medulla, and even the cerebral substance, 
have been involved, but to a lesser extent than the cord. 
As the anatomical seat of the lesion is principally in 
the anterior horn, the resulting symptoms expected 
are those of a purely motor character, with flaccidity, 
loss of reflexes, muscular wasting and absence or de- 
crease of electrical response. 

Symptomatology. — The disease, as a rule, begins 
abruptly with a rapid rise of temperature, accompanied 
by nausea, vomiting and diarrhea or constipation. 
Excessive sweating is often a premonitory symptom 
of great frequency. Pain is a very common symptom. 
The acute prodromal period may last from several days 
to two weeks. The paralysis usually occurs, or, rather, 
is discovered, on the third or fourth day. It is 
interesting to note the prodromal symptoms which 
occurred in some of the prominent epidemics. Collins, 
in a report of 500 cases in the New York epidemic of 
1907, found that 29 per cent, of the cases were char- 
acterized by high fever, and that the duration of the 
fever was from one to four days in a majority of 
the cases, and very infrequently longer than one week. 
Vomiting occurred in about 30 per cent, of the cases, 
diarrhea in 10 per cent., constipation in 17.6 per cent., 



140 FEVER NURSING. 

retention of urine in 7.4 per cent, of the cases. Fetid 
stools were noted in many cases in which neither con- 
stipation nor diarrhea was present. Three symptoms 
to which especial attention was directed were abdom- 
inal paralysis, retention of urine and constipation. The 
common symptoms were somnolence, stupor, rigidity of 
the neck, immobility, screaming and insomnia. V. P. 
Gibney, in a report of the same epidemics, as a result 
of studying 100 cases, found diarrhea and vomiting 
in 19 per cent., vomiting and constipation in 11 per 
cent. Starr's findings in the same epidemics were that 
the disease uniformly began with febrile manifesta- 
tions, and usually with vomiting, general sweating, se- 
vere pains in the limbs, with diarrhea on the second 
or third day. 

Motor Symptoms. — Paralysis. Motor paralysis 
forms one of the most important symptoms of infantile 
paralysis. The paralysis occurs after or during the 
abatement of the severe premonitory symptoms. Usu- 
ally in the course of several days, although it is not 
rare for these signs to occur very early ; the patient re- 
tiring at night in a normal condition, and in the morn- 
ing being affected with an extensive paralysis. 

The distribution and the extent of the paralysis 
varies exceedingly. It may involve only the muscles 
of a single group, or it may be of the hemiplegia, 
diplegia or monoplegia type, depending on the extent 
of damage in the cord. The primary paralysis is gen- 
erally much more extensive than that which will be 
permanent. It gradually subsides until only those 
groups of muscles presided over by the affected areas 
in the cord remain paralyzed. 



ACUTE EPIDEMIC ANTERIOR POLIOMYELITIS. 141 

From the knowledge of anatomy and physiology of 
the cord, we perceive that fibers from the anterior root 
cells leave the cord by way of the anterior nerve roots, 
and that these roots do not supply single peripheral 
nerves, but, by means of the plexuses, their fibers are 
distributed to a number of nerves ; thus, the anterior 
horn fibers are found not to supply anatomical groups 
of muscles, but physiological or like-functionating 
groups of muscles. Therefore, lesions of the anterior 
horns of the cord produce a paralysis of synergetically 
acting muscles, thus differing from nerve and brain 
lesions which affect anatomical groups of muscles. In 
anterior horn disease, two contra-functionating muscles 
lying side by side and supplied by the same nerve are 
differently affected ; the one being actionless, and the 
other normal. 

The muscles of the lower extremity are more often 
affected than those of the upper extremity; the ex- 
tension muscles being more often paralyzed than the 
flexors. Collins and Romeiser, in an analysis of 
500 cases of spinal infantile paralysis, found the dis- 
tribution of paralysis as follows : Leg, 43.2 per cent. ; 
both legs, 26.8 per cent. ; arm, 7.2 per cent. ; both arms, 
1 per cent. ; triplegia, 5.4 per cent. ; quadriplegia, 6.4 
per cent. ; homolateral, 4 per cent. ; crossed, 2.6 per 
cent. ; cranial nerve, 7 per cent. The frequency of 
the parts paralyzed : 1 — leg ; 2 — legs only ; 3 — arm ; 
4 — quadriplegia ; 5 — triplegia ; 6 — hemiplegia ; 7 — con- 
tralateral ; 8 — both arms only. The function of the 
sphincters are very seldom affected. 

Convulsions may occur during the prodromal stage, 
but are not common thereafter. 



142 FEVER NURSING. 

Reflexes. — As in all cases of inferior component 
paralysis, the reflex action is lessened or altogether 
abolished, depending on the extent of injury to the 
anterior horn cells of the respective reflex arcs. 

Muscle Tone. — As the anterior horn cells preside 
over the tonicity of the various muscles, an affection 
of this part of the cord produces a decrease or loss of 
muscular tone. Flaccidity of the muscles is very 
characteristic of infantile paralysis. The parts be- 
come loose and the joint action flail-like. 

Gait. — In anterior poliomyelitis, as the child begins 
to use the lower limbs in ambulation, a peculiar form of 
gait is noticed. As said above, the limbs are loose and 
the joints have a flail-like action; the legs are laxly and 
passively thrown forward, or may even be dragged 
along. 

Sensory Symptoms. — From the confinement of the 
lesion to the anterior horn or motor portion of the 
card, sensory symptoms are not to be expected, and 
this is the case, although in the prodromal stage severe 
pains in the limbs are not uncommon, but are probably 
due to the febrile or toxic disturbances, as in the other 
infectious diseases, typhoid fever, diphtheria or scarlet 
fever. 

Anesthesia and other sensory disturbances are ex- 
ceedingly rare. If the lesion of the anterior horn 
encroach on the pain tracts which cross in the central 
gray matter, then painful sensations may occur in the 
affected parts. 

Trophic Disorders. — Muscular Atrophy. The an- 
terior nerve cells preside over the nutrition of the 
muscles with which they are in relationship, therefore 



ACUTE EPIDEMIC ANTERIOR POLIOMYELITIS. 1 43 

a lesion affecting these cells as does anterior polio- 
myelitis produces muscular wasting. In this disease 
the muscular atrophy often reaches an extreme stage. 

Bone Dystrophics. — The bones in some cases are 
also affected. Their growth is retarded and in some 
cases entirely brought to a standstill. This, together 
with the muscular atrophy, makes the affected limb 
much smaller than its unaffected partner, both in 
length and bulk. 

Contractures. — Owing to the weakness of the 
affected muscles, there is great over-action on the part 
of the opposing muscles, thus producing various de- 
formities and contractures, such as the various forms 
of clubfoot, equinus positions, flattened arches, recurv- 
ing of the knee joint, deformities of the spine and 
shoulder and wrist. 

Owing to vasomotor disturbance, the affected parts 
are cold, mottled and discolored. Bed sores do not 
develop. 

Electrical Reactions. — As the inferior component is 
involved, changes in electrical reactions are prominent. 
The parts very early give a lessened response to faradic 
stimulation, and the characteristic reactions of de- 
generation rapidly make their appearance. 

Diagnostic Features. — The diagnosis of anterior 
poliomyelitis, as a rule, should not be exceedingly dif- 
ficult. Its prodromal febrile onset, followed by a 
purely motor paralysis of the inferior component type, 
should positively stamp it. Characteristic are the 
paralysis of physiologial or like-functionating groups 
of muscles, with flaccidity, rapid atrophy of the mus- 
culature, loss of reflex action in the affected parts, 



144 FEVER NURSING. 

presence of an altered electrical response with the 
reactions of degeneration, with the absence of sensory 
symptoms. 

Care and Management. — The States of New York 
and Massachusetts have added this disease to the list 
of communicable diseases. It may be well to insert 
here a few excerpts from a circular issued by the New 
York State Department of Health : 

Epidemic poliomyelitis has been added to the list of 
communicable diseases, the occurrence of which is re- 
quired by the State Department of Health to be re- 
ported to local health officers, and by them to the 
department. 

Since 1881 medical literature has contained reports 
of outbreaks of infantile paralysis, during the last five 
years these outbreaks in several parts of the world 
have increased in frequency out of proportion to the 
increased interest shown in the disease. That is, the 
increased number of reports cannot be attributed 
wholly to more accurate diagnosis or greater care in 
reporting the cases. 

The disease is found to be more prevalent in cold 
than in warm countries, and more cases have been 
reported from the northen part of the United States 
than from any other part of the world. It occurs 
mostly in children, but adults have been afflicted. In 
1907 there was an epidemic of 2500 cases in New 
York, the largest ever reported. It generally begins 
late in the summer, and ends after a few hard frosts 
in October. 

Laboratory workers have already demonstrated that 
infantile paralysis is an infectious disease, caused by 



ACUTE EPIDEMIC ANTERIOR POLIOMYELITIS. 145 

a living organism, so small that it can pass through 
a bacterial filter. It is thought to be most contagious 
during the early, or febrile, stage of the disease. Most 
of the laboratory study has been made upon monkeys, 
who acquire the disease by inoculation of an emulsion 
of certain tissues from a human being dying of the 
disease, and from affected monkeys. 

With a view to the prevention of the disease, the 
State Department of Health expects that every case 
discovered will be quarantined. Some local boards of 
health have already passed an ordinance requiring a 
quarantine in this disease, and such action is approved 
by the department. The discharges from a patient — 
stools, urine, sputum — should be disinfected. 

The patient should be isolated, in order to protect 
other members of the family and the community in 
general. The excretions, especially those from the 
nose, mouth, kidneys and bowels should be thoroughly 
disinfected, as described under typhoid fever. The 
bowels should be thoroughly evacuated for two rea- 
sons ; first, constipation is very common ; second, 
whether constipation or diarrhea prevails, the bowel 
content is often fetid. The result may be attained 
by the use of castor oil, enemata, or both. The child 
should be urged to freely partake of liquids, especially 
water, and if because of vomiting or other reasons, 
sufficient water is not taken, it may be given by the 
rectal saline drop method, which acts very favorably 
and increases the functions of the kidneys. The skin 
may be made active by means of hot packs or hot 
air baths. 

The diet, as in all febrile conditions, should be light 

10 



I46 FEVER NURSING. 

and nourishing. Milk in one or more of its many 
modified forms should be the basis of feeding. Cereal 
gruels, albumen, water broths, ice cream, gelatine and 
fruit juices may be used to vary the diet. 

High fever should be met with one of the many 
hydrotherapeutic measures described in succeeding 
chapters. An ice bag to the head may quiet delirium. 
A hot bath will often relieve muscular spasm. As the 
disease progresses from the acute stage into the per- 
manent stage, the use of electricity, massage, passive 
and active exercise and baths may be employed to help 
the return of normal muscular and nerve functions. 

The Great Ormond Street Hospital for Children, 
in London, issues a small circular regarding the care 
of paralyzed limbs, which I herewith add, in part : 

Clothing. — The paralyzed parts must be kept warm 
day and night. 

Knitted woolen stockings to come up above the 
knees must be worn. 

If these do not keep the limbs warm, woolen over- 
alls must be worn outside the stockings. 

The overalls must be lined, if necessary, with cotton 
wadding quilted to them. 

For the night, a flannel sack made the shape of the 
leg, coming up to the top of the thigh, and lined with 
cotton wadding, is best. 

Rubbing. — This must be done for a quarter of an 
hour twice daily. 

Lay the child on a bed. 

1st. Rub the paralyzed leg from the foot right up to 
the top of the thigh. Rub upwards only. Put the 
broad part of your hand on the back of the child's 



ACUTE EPIDEMIC ANTERIOR POLIOMYELITIS. 147 

leg. In rubbing the thigh, put you hand first on the 
back of the thigh, and afterward on the front, but 
always rub upward, and be sure to go as high as the 
child's loins. While rubbing with your right hand, 
hold the child's foot with your left. Use for rubbing 
any kind of oil. 

2d. Take hold of the child's leg with your two 
hands just above the ankle. Rub around the leg with 
your two hands in opposite directions, as though you 
were wringing out sheets. Work up the leg and thigh 
from the foot to the top of the thigh, in the above 
manner. 

3d. Flip every part of the leg and thigh with your 
fingers, so as to make the whole of the limb quite red 
and warm. 

Rub gently up and down all over. This will take 
away the stinging which was left by the last movement. 

Baths. — Once a day let a large jugful of hot water, 
containing two hands ful of salt, be poured down the 
leg and thigh. 

Then pour about half the quantity of cold water 
over the leg and thigh. 

Then rub thoroughly with a towel until the limb is 
perfectly warm and dry. 



CHAPTER XVII. 

LOBAR PNEUMONIA. 

Definition. — Lobar pneumonia is an acute infec- 
tious fever, characterized by inflammation of the lungs, 
with symptoms of general toxemia. The lesion is due 
to a specific bacterium — the pneumococcus. 

Synonyms. — Croupous pneumonia, fibrinous pneu- 
monia, pleuropneumonia, pneumonitis, lung fever. 

Etiology. — The exciting cause is the pneumococcus. 

Predisposing causes are the Fall and Winter sea- 
sons, exposure to the elements, cold and rain. Elderly 
and enfeebled persons are very susceptible. The use 
of alcoholic beverages to excess, lowering the resist- 
ance of the individual, pre-existing diseases as diabetes, 
nephritis, typhoid fever, and injury to the thorax may 
precipitate an attack. 

The germ causing pneumonia is said to have been 
found in the mouths of sixty per cent of individuals. 

Pathology. — The course of the pathologic events 
are divisible into three stages. 

First stage consists of engorgement or congestion 
of the lung. It lasts from twelve to thirty-six hours. 
If the patient die in this stage, the lung will be found 
very red, and when cut the blood drips from it. It 
crepitates when pressed between the fingers and when 
placed in water it floats midway. 

148 



LOBAR PNEUMONIA. 149 

Second stage or the stage of red hepatization. The 
lung is very solid due to the great amount of fibrinous 
exudation, and resembles very much the consistency 
of the liver and is red in color. From these two facts 
the condition derives its name. 

The cut surface of a lung in this stage is granular 
and somewhat dry. There is no dripping of blood. 
When placed in water it sinks to the bottom. It does 
not crepitate on pressure. 

Third stage or stage of gray hepatization. The exu- 
date of the former stage is now undergoing certain 
degenerative changes and becomes gray in color and 
more fluid. When placed in water it floats. 

Symptoms. — The onset of lobar pneumonia is usu- 
ally abrupt. There may be a day or two of malaise, 
headache, and loss of appetite, but as a rule it begins 
suddenly with a chill. The chill is very severe and 
pronounced, sometimes lasting from twenty to thirty 
minutes and so vigorous as to shake the bed if the 
patient be in bed at the time. The temperature rises 
rapidly and to a high point (104 to 106 F.) ; there 
is a sharp stabbing pain in the side, especially pro- 
nounced on coughing or breathing deeply, and is due 
to an acute pleurisy. 

Cough appears early and is short and suppressed 
because of the pain it causes. The sputum is very 
characteristic in the first part of the disease. It is' 
scant in amount, very viscid, and of a reddish, rusty 
color. If the cup in which the patient expectorates be 
inverted, the sputum, on account of its viscidness, 
clings to the walls of the cup and does not fall out. 



i5° 



FEVER NURSING. 



The respirations become very rapid and at times 
irregular. 

The face is flushed and the flush is said to be greater 
on the side in which the pulmonary lesion is situated. 

Herpes labialis is very common in this disease. The 
alae nasi dilate on inspiration, and the grunt on expira- 
tion is more or less characteristic. 

The tongue is coated, the mouth dry, nausea and 
vomiting are not uncommon. 



JSTf 










































M 


E 


M 


E 


M 


E 


ME 


M 


E 


m|e 


ME 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 




107 

106 




































































108 
107 
106 








104 
103 

ioa 

101 

100 
99 
93 
97 




































































104 
103 




















102 
101 
















































































































































99 




















98 










97 



Fig. I4-' — Temperature chart of lobar pneumonia. 

The urine is scant in amount, highly colored, of a 
high specific gravity, and contains a small amount of 
albumen. 

Fever. — The temperature, as said above, becomes 
rapidly high ; after reaching its fastigium it usually 
remains at a common height for a few days, and may 
then suddenly fall by crisis. Two or three days before 
the crisis there may be a pronounced fall in the tem- 
perature, but it soon reaches its height again. This 
fall is known as the pscudocrisis. 



LOEAR PNEUMONIA. 151 

It has often been noted that just before the occur- 
rence of the crisis the patient, who has hitherto been 
restless, will fall into a quiet sleep — the precritical 
sleep. 

The crisis is accompanied by a drenching sweat after 
which the patient becomes very comfortable. 

Nervous Symptoms. — In children and young persons 
convulsions may usher in the disease. Delirium of an 
active type may occur, especially in persons of alcohol 
habit. 

Varieties. — Infantile Pneumonia. Instead of be- 
ginning with a chill this type in many instances is 
ushered in with a convulsion. Vomiting is of frequent 
occurrence. The course is not regular. 

Pneumonia in the Aged. — The temperature is not as 
high as in young adults. The pulse is rapid, feeble, and 
irregular. The temperature usually falls by lysis. 

Wandering Pneumonia. — This form moves from 
place to place. It may start in the lower lobe of one 
lung and then migrate to the other lung. If the course 
be slow and it resolve in one place while it is acute in 
another, the prognosis is not so bad. 

The typhoid form is of a nervous type. The tongue 
is dry, delirium is common, and the usual toxic symp- 
toms seen in typhoid fever are present. 

Central Pneumonia. — In this form a patch of cen- 
trally located lung is involved. The physical signs are 
absent at first. 

Complications. — Pleurisy is of very frequent oc- 
currence as the dry form. Empyema frequently fol- 
lows and may be serious. 

Pericarditis is not uncommon. I have seen a most 



152 FEVER NURSING. 

grave pericarditis with great effusion follow a pneu- 
monia of a very mild type. 

Endocarditis is frequent, especially in pneumonia in- 
volving the left lung. 

Other complications are meningitis, edema of the 
lungs, delayed resolution, nephritis, and neuritis. 

Prognosis depends on age; under twenty months 
the disease is usually fatal. Between the ages of two 
and eight years it is favorable if the child be not rick- 
ety. It is very favorable in young, adult life, but be- 
comes a serious and grave disease in elderly people. 

Toxemia alters the prognosis. Severe toxemia is 
always serious. 

Situation. — Central pneumonia is serious and next 
in gravity is involvement of the upper lobe. 

Symptoms. — Active delirium causes exhaustion. 
Low temperature with rapid pulse is grave. Pul- 
monary edema is usually a forerunner of a fatal 
termination. 

If the crisis be prolonged beyond the ninth day and 
resolution be delayed, be suspicious of tubercular in- 
volvement. 

Course. — The disease may terminate by resolu- 
tion and absorption and excretion of the exudate. 
Resolution may be slow and delayed but eventually be 
complete. Chronic interstitial pneumonia may result. 
Gangrene or abscess of the lung may follow, with fatal 
termination. 

Care and Management. — The germs of pneumonia, 
as those of tuberculosis, are probably distributed in 
the dry dust of the air, and thus gain entrance to the 
respiratory tract of the human organism. These germs 



LOBAR PNEUMONIA. 153 

if they be particularly virulent or if the resistance of 
the individual be lowered, will begin to multiply. It 
will thus be seen that if a person is to be protected 
from contracting pneumonia, he must maintain his 
bodily resistance and not expose himself to such de- 
bilitating influences as cold, wet, poorly ventilated apart- 
ments, etc. 

Pneumonia is also without doubt a communicable 
disease. 

General Management — The patient should be in a 
well ventilated, large room with plenty of air. He 
must remain quietly in bed and not be allowed to leave 
it until at least ten days after the crisis. Absolute rest 
is a necessity of prime importance; the patient is not 
to exert himself in any way. There are many exam- 
ples of a sad and fatal ending of a pneumonia patient 
who seemed in excellent condition, but who, thinking 
himself strong, moved suddenly in bed and caused a 
fatal dilatation of the heart. 

The diet should be light, very nourishing and chiefly 
liquid. Milk will form the main article of diet and 
may be supplemented daily with a raw egg or two, 
albumin water, and some standard preparation of pre- 
digested beef. After the crisis semisolid and solid ar- 
ticles of food may be given gradually. 

The bowels should be kept open by enemata. If the 
temperature be high, nervous symptoms prominent, 
and the heart action weak, hydrotherapy should be 
resorted to. Baths should not be given as freely as 
in typhoid fever. Three or four in twenty-four hours 
are sufficient. The water used should be about 85 ° F. 
or 90 F. 



154 FEVER NURSING. 

The continuous use of the ice-cap is a most excellent 
means of applying cold, and is agreeable and com- 
fortable to the patient. An occasional alcohol rub will 
also serve its purpose. 

Sleeplessness is one of the most troublesome symp- 
toms of pneumonia. If the physician does not care to 
resort to hypnotics for certain reasons, then local meas- 
ures must be used. A hot drink, an ice-bag to the 
head, a mustard foot bath, or a tepid sponge are all 
serviceable. 

For the severe pain in the side, usually prominent in 
the beginning of the attack, nothing is more useful as 
a local application than an ice-bag. If the patient ob- 
ject to this, a mustard paste may be substituted, or hot 
fomentations. 

The heart is the one organ on which the bulk of the 
burden falls. It is to this organ that a most careful 
vigilance must be directed. If the rate become high, 
the action irregular and tumultuous, or the rhythm 
altered, the nurse will understand that the organ is 
beginning to be affected and the physician's attention 
should be called to it immediately. 

For a tumultuous heart the ice-bag is of most valu- 
able service. 

During the crisis support and stimulation is of par- 
amount import. 

The drugs generally used in this disease for heart 
stimulation are digitalis, strychnin, alcohol, and atro- 
pin. If a very rapid stimulation be necessary as at the 
crisis, aromatic spirits of ammonia or the compound 
spirits of ether may be given every hour or two in 
half-dram doses, well diluted. 



LOBAR PNEUMONIA. 1 55 

If cyanosis and dyspnea are present, then oxygen 
may be administered. In profoundly toxic cases, the 
use of normal saline solution as a hypodermoclysis is 
very useful. 

It may very rarely fall to the lot of a nurse to per- 
form or assist at a venesection. This is generally per- 
formed on the front of the arm at the elbow joint. 

The part is first thoroughly cleaned as for a minor 
operation. A rubber bandage or tourniquet is placed 
around the arm above the elbow, causing the veins 
below to become very prominent. An incision one- 
half inch in length is made over the site of one of the 
veins, generally the median cephalic. When the an- 
terior wall of the vein is incised the flow of blood is 
free, provided the tourniquet is not so tight as to inter- 
fere with the arterial supply of the forearm. When 
sufficient blood has been removed, from one-half to 
one pint, a sterile pad is placed over the incision and 
a bandage firmly applied. The dressing need not be 
removed for five or six days. 

Management of Pneumonia in Children. — The 
care of a child ill with pneumonia differs somewhat 
from that of an adult. The child should be confined to 
bed in a large, airy room. The temperature should be 
equable (about 68° F.). Quiet should prevail; loud 
talking within the room or in hearing distance of the 
patient is to be prohibited. Fresh air and ventilation 
are of prime importance. 

Dr. Wm. P. Northrup of New York has said : "If 
you wish to kill a child with pneumonia, then place the 
crib in a far corner of the room with a canopy over it. 



I56 FEVER NURSING. 

Have the temperature of the room 8o° F. Have many 
gas jets burning, shut the doors and windows, place a 
large poultice around the child's chest, and have a few 
friends in the room." 

The diet should consist of milk only. If the child 
be very young, the milk should be modified as given 
in the chapter on "The Diet of the Sick." Special care 
must be given to the diet. Milk very frequently causes 
distention of the abdomen which seriously interferes 
with the action of the heart. Water should be freely 
given. 

The bowels must be evacuated at least once a day. 

Fever in a child is not as significant as in an adult. 
Often it nee*d not be treated, unless it mounts very 
high, or is accompanied by restlessness and nervous 
phenomena, when tepid sponges and cool packs will be 
very serviceable. 

A thick bath towel is immersed in water at 85 ° F. 
to 90° F., and then wrapped about the child's chest 
and trunk, and a light blanket thrown over the child. 
If in ten minutes the results are not satisfactory, repeat 
the procedure, using water which is a little cooler. 

'Cold and clammy feet are often seen in this class 
of cases. In these patients a hot foot bath is of great- 
est benefit. Watch the feet ! Counter irritation to the 
chest in the form of a weak mustard paste is often 
serviceable. 

Convalescence in pneumonia, as a rule, is very 
rapid and may be greatly enhanced by nourishing diet 
and tonics. 



CHAPTER XVIII. 

DIPHTHERIA. 

Definition. — Diphtheria is an acute, infectious 
fever, caused by the Klebs-Loffler bacillus and charac- 
terized by the pseudomembranous inflammation of 
certain mucous membranes and by general toxemia. 

Etiology.— The exciting cause is the specific bacil- 
lus mentioned above. Predisposing causes are expos- 
ure to cold and wet ; tonsillitis and pharyngitis, which 
lessen the resistance of the mucous membrane. The 
time of greatest susceptibility is between the ages of 
six months and six years. Adults are not so liable to 
contract this disease as are children. The force of 
the infection is not always equal ; some epidemics are 
more severe than others, and some individuals are 
attacked more vigorously than others. 

The bacilli themselves usually remain at the site of 
the local lesion, but the toxins which they produce are 
absorbed and give rise to the general toxic symptoms. 

The tonsils afford an excellent residence for the 
'germs as the crypts of the tonsils usually contain ma- 
terial upon which the bacilli may subsist and also pro- 
vide two important requisites to the multiplication of 
bacteria; namely, heat and moisture. 

At first only a hyperemia of the mucous membrane 
is produced, but later an exudation is thrown out, 
which sinks into the tissues and is followed by a ne- 

i57 



158 FEVER NURSING. 

crosis of the superficial layers, forming a false or pseu- 
domembrane. Great edema of the parts and abscesses 
may develop. 

This pathologic process just described may occur on 
any mucous membrane, as of the tonsil, pharynx, lar- 
ynx, nasal cavity, esophagus, stomach, vagina, con- 
junctiva, etc. 

The membrane is at first gray but soon becomes of 
a dirty brown color. It cannot be readily removed, 
and if taken off, leaves a raw, bleeding surface. 

Degeneration of the nerves, heart, kidneys, and liver 
are common. 

Symptoms. — The disease usually begins insidi- 
ously with malaise, loss of appetite, feverishness, sore 
throat, and difficulty in swallowing. Chilliness or a 
chill may usher in the attack. 

The throat is at first reddened, and soon white 
patches appear on the tonsils and pillars of the fauces. 
These patches soon coalesce and spread to the soft pal- 
ate. The patches first gray, become brownish and are 
not easily detached. These patches may be confined to 
the larynx or nasal cavity with little or no involvement 
of the tonsils and soft palate. 

The patient becomes more or less hoarse and a brassy 
cough develops, especially if the larynx be affected. 

Prostration is marked. The patient becomes rapidly 
anemic. The pulse is rapid and feeble. Nasal breath- 
ing may be difficult. The glands of the neck become 
enlarged. 

The temperature varies but does not reach a great 
height unless severe toxemia or complications occur. 



DIPHTHERIA. 159 

In the laryngeal form there is hoarseness which may 
be succeeded by aphonia. The cough is barking and 
brassy. There are paroxysms of dyspnea and cyanosis. 
The symptoms become worse at night. This form is 
usually very severe. 

Complications and Sequelae. — Hemorrhages may 
occur in the skin, kidneys, or nose, due to a fatty de- 
generation of the vessel walls. 

Pneumonia is a very common complication. 

The toxins of diphtheria seem to have an especial 
affinity for the heart and cardiac degenerations are of 
frequent occurrence. 

The kidneys are also attacked by the toxin and 
Bright's disease often complicates diphtheria and shows 
itself by an increase of albumen in the urine, and the 
presence of casts and blood. 

The enlarged cervical glands may soften and ulcer- 
ate. 

The most important sequelae are the nerve degenera- 
tions with their accompanying paralyses. The nerve 
sequelae occur as a rule after convalescence has ad- 
vanced for two or three weeks. 

When the nerves of the pharynx and surrounding 
structures are involved there results a series of char- 
acteristic paralyses. The muscles of the pharynx and 
soft palate, as a rule, are the first to suffer. The voice 
takes on a nasal tone, food given by the mouth re- 
gurgitates through the nose, swallowing is difficult 
and impeded. 

Other nerves of the body are also affected. There 
may be strabismus, ptosis, loss of power of accommo- 
dation, and facial paralysis may occur. The muscles 



l6o FEVER NURSING. 

of the neck may be affected and weakened when the 
head will lean to one side or roll about on the shoul- 
ders. 

The upper extremities are rarely involved. 

The legs may be affected and the knee jerks dimin- 
ished or lost. 

Prognosis. — This depends on the early use of 
antitoxin and the complications. Before the use of 
antitoxin, the mortality was from forty to seventy per 
cent. 

Mortality of cases treated with antitoxin on first 
day i per cent. 

Mortality of cases treated with antitoxin on second 
day 4.3 per cent. 

Mortality of cases treated with antitoxin on third 
day 14.2 per cent. 

Mortality of cases treated with antitoxin on fifth 
day 19 per cent. 

Involvement of the larynx, complications of the 
heart and kidneys are very grave. 

Transmission. — The excretions from the nose and 
mouth are loaded with infection. Therefore, they 
should be carefully collected, and not thrown on the 
carpet or placed in handkerchiefs and allowed to lie 
around. These excretions when dry become pulver- 
ized and are then suspended in the air and inhaled, 
thus spreading the disease. During the coughing spell 
the excretions may be discharged into one's face. 

The infection may also be conveyed on eating uten- 
sils, pencils, clothing, etc. The germs may linger in 
the throat for weeks after the disease subsides. 



DIPHTHERIA. l6l 

Care and Management. — After the administration 
of the antitoxin there is little to be done besides pre- 
venting the spread of the disease, treating the disease 
locally, attending to the comfort of the patient, and 
being prepared to combat complications should they 
arise. 

Prevention of the spread of the disease is very im- 
portant. It is hardly necessary to say that absolute 
isolation of the patient is the first requisite. Members 
of the family are not to be allowed in the patient's 
room. Children in the same house with a patient suf- 
fering from diphtheria are not to attend school. All 
persons in the house, or who have been exposed to 
the disease, should be immunized by small doses of 
antitoxin (500 units). If objection be made to this, 
then at least those who have never had the disease 
should be protected by this immunizing dose of 
antitoxin. 

The room in which the patient is to lie should be 
large, airy, light, and capable of being ventilated. If 
a room with a fire-place can be used, it would afford 
better ventilation. All furniture, hangings, etc., that 
are not essential to the comfort of the patient and nurse 
should be removed. A comfortable bed, a large table, 
and one or two chairs is all the furniture necessary. 

The temperature of the room should be kept equable, 
at about 65 ° F. Avoid having the patient exposed to 
draughts. A separate set of eating utensils should be 
used in the sickroom. 

Allow no uncovered dishes of food or medicines to 

remain about the room. When the patient has drunk 

all the milk he cares to, do not place the glass contain- 
11 



162 FEVER NURSING. 

ing the residue of milk on the table, but remove it at 
once and cleanse it. 

Always have a basin of some antiseptic solution 
handr, preferably corrosive sublimate solution (i- 
iooo). 

Keep the floor and furniture scrupulously clean. If 
dishes are washed in the general kitchen, thev should 
be thoroughly immersed in a strong antiseptic solution 
before leaving the sickroom. Do not place metallic 
dishes, etc., in solutions of corrosive sublimate. 

Bed clothing and the patient's gowns should be fre- 
quently changed. Soak well in a strong antiseptic so- 
lution before sending them to the laundrv. 

One person should care for the patient, and all 
others, excepting the medical attendant, should be ex- 
cluded from the sick-room. The person in charge 
should not mingle with other members of the house- 
hold ; as in all contagious diseases, visitors should not 
be admitted to the house, nor members of the house- 
hold allowed to visit others. 

A few words to the nurse about the protection of 
herself will not be here misplaced. Always immerse 
your hands in an antiseptic solution after attending to 
the patient. If it be required of you to make local appli- 
cations to the throat or nose of the patient, be very 
careful as you are on dangerous soil. It is well to 
hold, or have held, a large square of glass (at least 
twelve inches square) between your face and that of 
the patient when making applications. When the pa- 
tient coughs, which he is liable to do when you are 
making local applications to the throat, myriads of the 
germs may be expelled. 



DIPHTHERIA. 1 63 

Spray your nose and throat frequently with some 
antiseptic solution. Do not sleep or eat in the patient's 
room. Wear only clothing that may be easily 
laundered. 

The diet is the same as in any acute febrile disease ; 
namely, milk, gruels, broth, etc. It is very important 
that food be given regularly and that the patient get 
a sufficient quantity as the whole system is greatly de- 
pressed, and nourishing and easily assimilated food will 
help the system to overcome the action of the toxins. 

The same care must be exercised in regard to the 
excretions and secretions as in typhoid fever. In diph- 
theria the excretions of the nose and throat are of 
special importance as they are exceedingly virulent. 
Soft linen cloths or pieces of old muslin should be 
used for collecting the nasal and pharyngeal secretions. 
These cloths when soiled must be burned immediately 
and no attempt should be made to wash and use them 
again. Do not use cups for collecting the sputum, for 
in expectorating in a cup more or less of the material 
is sprayed into the air. 

Local Treatment. — It is very important to keep 
the mouth, nose and throat scrupulously clean. This 
may be done by the judicious use of antiseptic solu- 
tions in the form of spraying, atomizing, swabbing, 
gargling, and douching. Solutions to be used for this 
purpose are numerous ; boric acid, four per cent ; po- 
tassium permanganate, one to two thousand ; and per- 
oxid of hydrogen, one to eight. 

Local applications to the false membrane itself was 
a prominent part of the treatment before the days of 
antitoxin, but they are seldom employed now. 



164 FEVER NURSING. 

General Treatment. — The administration of diph- 
theria antitoxin holds first place by far in the general 
treatment of this disease. The initial dose of the anti- 
toxin must be of sufficient quantity. At least three 
thousand units should be administered and repeated at 
short intervals until the required action is obtained. 
The danger is not in giving too much, but in giving 
too little. 

The use of antitoxin should be followed, in at most 
twelve hours, by a decrease in the severity of all symp- 
toms. The temperature is lessened, restlessness is 
quieted, sleep is oncoming, and the patient becomes 
brighter. The local manifestations of the disease show 
improvement, the swelling and edema of the mucous 
membrane is lessened. The edges of the false mem- 
brane begin to retract and to quickly disappear. 

The duration of the disease is shortened and the 
prognosis is greatly brightened. If any organic changes 
have taken place in the nerve fibers or the heart, these 
are not repaired by the giving of antitoxin, but their 
advance may be checked. 

Certain ill effects of but minor importance some- 
times follow the administration of antitoxin, and are 
due, not to the antitoxin, but to the horse serum of 
which it is composed. The nurse should bear in mind 
these ill effects so that if they occur, she will under- 
stand their cause. 

These complications may appear in the form of a 
rash, which is an erythema in character and may re- 
semble the eruption of scarlatina or of rubeola ; or it 
may be of an urticarial nature appearing as small 
wheals like a mosquito bite, and may itch. The rash 



DIPHTHERIA. 165 

may occur within ten minutes or many days after the 
injection of antitoxin. A complication may occur in 
the joints characterized by swelling of the joint and 
more or less pain. The temperature may mount very 
high. 

These ill effects are not dangerous, but unless ex- 
pected, may cause some confusion. 

Method of Administration of Antitoxin. — The site 
of injection is elective: the femoral or gluteal regions, 
or preferably in the interscapular space. The area 
should be well cleaned with soap and water and then 
treated with an antiseptic solution and rinsed with 
sterile water to remove the antiseptic. Some physi- 
cians simply clean the area with alcohol. The syringe 
and needle with which the antitoxin is to be given 
should be sterilized. At present all the larger manu- 
facturers of antitoxin provide a sterile syringe and 
needle with the serum. The needle should be inserted 
as is a hypodermic needle, but more deeply, and the 
serum slowly injected. 

Fever if high, is treated with cold sponges and baths 
as in other febrile disorder. 

The soreness of the throat and neck is best relieved 
by the application to the neck of an ice-bag. Small 
pieces of ice in the mouth are very useful in older 
patients. 

For swollen glands apply an ointment of ichthyol or 
belladonna. 

In laryngeal forms the air of the rooms may be 
moistened by means of a steam kettle; or filling the 
room with the vapors from ten grains of burning cal- 
omel is useful. 



1 66 FEVER NURSING. 

In the nasal form the nose should be irrigated with 
normal saline solution. 

Intubation was employed to a considerable extent be- 
fore the days of antitoxin. It is well for a nurse to 
know how to prepare a child for the operation, so in 
case she be called upon, she will be acquainted with 
the methods. 

Fold a sheet or blanket until it is just wide enough 
to extend from the chin of the child to the feet. Wrap 
this about the patient so that the whole body except 
the head and neck is included. Have the arms of the 
child extended along the side of the body before apply- 
ing this binder. The sheet should be applied somewhat 
tightly to prevent the child from struggling with the 
arms and legs. Pin the binder snugly but do not have 
a bulky roll at the upper end as it will interfere with 
the operator. 

The nurse sits upright, preferably on a stool, placing 
the child's wrapped legs between her knees and hold- 
ing them very firmly in this position. With her hands 
the nurse grasps the child's elbows, having the head 
resting against her left shoulder. The object is to 
thoroughly immobilize the child without interfering 
with its respiration or the operator's field of work. 

Another nurse stands behind the child and grasps its 
head firmly between her two opened hands ; with her 
left hand she also steadies the mouth-gag, which is 
placed in the child's mouth on that side. The patient 
is now in the best position for intubation. 

Feeding the intubated patient is the next perplexing 
problem. Swallowing is more or less painful and dif- 
ficult. Particles of food often enter the larynx and 



DIPHTHERIA. 167 

cause not only severe fits of coughing, but may also 
cause an expulsion of the tube during the paroxysm. 

There are several methods of feeding an intubated 
child. In the first method the child's head is placed 
lower than the level of the body and then fed slowly. 
Place the child on its back across the lap of the nurse 
with its head low. This may be accomplished by hav- 
ing a pillow under the child's buttocks, or by the nurse 
raising her knee on that side. Then feed the patient 
either with a spoon or from a nursing bottle. This is 
very awkward to the child at first, but it soon learns to 
swallow without difficulty or coughing. 

A second method is by passing a small rubber 
catheter through one of the child's nostrils, down the 
esophagus into the stomach. Care must be taken that 
the catheter does not enter the larynx and intubating 
tube. With a small funnel inserted into the free end 
of the catheter milk can be easily introduced into the 
stomach. 

If both of these methods fail, then rectal alimenta- 
tion must be employed. 

Quarantine. — The patient should remain in bed ten 
days after the disappearance of the membranes, when 
the throat is examined for the presence of the diph- 
theria bacilli, which, if found, will prolong the period 
of quarantine. If none are found by repeated exam- 
ination, and all symptoms have disappeared, the child 
may be permitted gradually to resume its former mode 
of life. 

The room, all its contents, and the clothes of both 
patient and nurse must be thoroughly disinfected. For 
the method of disinfection see the Chapter on Scarlet 
Fever. 



CHAPTER XIX. 

ACUTE ARTICULAR RHEUMATISM. 

Etiology. — The exciting cause of the disease is 
at present unknown. It is supposed to be of bacterial 
origin. 

Predisposing causes are exposure to cold and wet 
especially ; it is more prevalent in damp seasons and 
after prolonged dry seasons. Early adult life is a pre- 
disposing factor, particularly between the ages of ten 
and thirty years. Occupations which expose the indi- 
vidual to the elements excite the disease, which at 
times seems to occur in epidemic form. Most cases are 
seen in the latter part of Winter or Spring. 

The disease is thought to be caused by a germ be- 
cause it begins with symptoms generally connected 
with the acute infectious diseases, as sore throat, ma- 
laise, headache, etc. ; because there is a tendency to 
relapse ; because it occurs in epidemic form ; because 
the symptoms and complications resemble those of 
bacterial diseases ; and, finally, because it is usually 
accompanied by anemia. 

Reasons for believing it not to be due to germs are : 
No germ has been found ; it has a hereditary tendency ; 
it recurs in the same individual. 

1 68 



ACUTE ARTICULAR RHEUMATISM. 169 

Another theory ascribes its cause to a toxemia due 
to the presence of acetic acid or uric acid in the blood ; 
and another holds it to be of nervous origin. 

Allies of rheumatism are chorea, follicular tosillitis, 
and torticollis. 

Symptoms. — The disease may be ushered in grad- 
ually by a few days of discomfort, malaise, loss 
of appetite, and other indefinite symptoms; or it 
may commence suddenly with a chill or chilliness. 
Sore throat and tonsilitis are frequent forerunners of 
acute rheumatism. They occur in from thirty to sixty 
per cent of cases. In the course of a few days the 
joint symptoms begin to make their appearance. The 
joints which are attacked become very painful, and 
redness and swelling of the affected joints soon appear. 
The joints become exquisitely tender and even the 
weight of light bed clothing cannot be borne. The 
tissues about the joints may be greatly swollen, or 
even the whole limb. 

The pain is excruciating and is produced by the 
slightest movement. One characteristic is the rapid 
migration of the joint symptoms. 

The temperature varies from 102 F. to 103 F., but 
may reach a very great height. Hyperpyrexia is not 
uncommon in acute rheumatic fever. The pulse be- 
comes rapid and may be irregular. 

A very characteristic symptom is the profuse, drench- 
ing sweats. The perspiration is acid and has a sour, 
foul odor. The temperature falls after the sweat. 
Miliaria and sudamina are of frequent occurrence. 

The tongue is coated, the bowels are constipated, and 
the appetite is lost. 



i;0 FEVER NURSING. 

The urine becomes very acid, scanty in amount, dark 
in color, high in specific gravity, and contains an abun- 
dance of urates. The person becomes very anemic due 
to an alteration of the blood by the toxic substance. 

Complications. — Endocarditis, pericarditis, and 
myocarditis are the principal cardiac complications. Of 
these endocarditis is the most frequent and most seri- 
ous. The mitral valve is usually affected. Small veg- 
etations form on the line of closure of the valves. In 
these vegetations germs have been found. Rise in tem- 
perature., palpitation of the heart, and change in the 
pulse character will denote the onset of this complica- 
tion. 

Pericarditis may be of the dry or moist form. The 
moist form may be serous, purulent, or hemorrhagic. 
It may develop at any stage of the disease. Heart 
complications are known to have developed before the 
joint symptoms have appeared. 

Pleurisy with effusion of one or both sides may oc- 
cur. 

Other complications are hyperpyrexia, meningitis, 
delirium, convulsions, coma, chorea, pneumonia, ne- 
phritis, erythema nodosa, purpura, and hematuria. 

Course. — In mild cases the joint symptoms dis- 
appear in two or three days, the temperature falls but 
the sweats may continue. Relapses are frequent and 
point to an infectious nature. Hyperpyrexia, menin- 
gitis, and heart complications are unfavorable. Death 
may occur suddenly, due to myocarditis. The disease 
may become subacute or chronic. 

Care and Management. — The room in which the 
patient is confined should be airy and well ventilated. 



ACUTE ARTICULAR RHEUMATISM. 17 1 

Absence of draughts of air is very essential. The tem- 
perature of the room should be kept constantly at or 
near 68° F. 

The patient should wear a light flannel gown and 
undershirt, as flannel absorbs moisture very easily 
and will protect the patient from the cold. The patient 
for the same reasons should sleep between blankets and 
not sheets. 

The diet is to be liquid. Milk will form the bulk of 
the diet during the acute stage. If whole or undiluted 
milk does not agree with the patient, it may be diluted 
with Vichy, barley water, limewater, or even plain 
water. Buttermilk, skim milk, albumin water may 
form part of the diet. No meat or meat preparations 
should be given during the course of the disease. 

Thirst is as a rule constant and great. It may be 
relieved by providing water freely. Lemonade, oat- 
meal water, and seltzer water are allowable. 

The basis of all medication is salicylic acid or some 
of its salts, the salicylates. These preparations are 
more or less disagreeable to take and may upset the 
stomach. The patient will consider it a favor if these 
medicines be administered in an agreeable form. The 
salicylates may be given dissolved in milk, or dissolved 
in milk and peptonized, forming a curd or sort of a 
salicylized junket. Another palatable form is prepared 
by dissolving the drug in water and adding some gly- 
cerin. 

Local Measures. — These are without number. Of 
all applications there are three or four which I have 
found of special service. First and foremost the ice- 
bag. Even the mentioning of this to the patient will 



T72 FEVER NURSING. 

make him shudder. He will even rebel against it. It 
may require a little diplomacy on the part of the nurse 
to carry out this method, but after the first application 
the patient does not object as the results are very 
gratifying. Do not place the bag next to the skin but 
have a piece of woolen cloth intervene. 

Second, an application consisting of one dram of 
salicylic acid, one ounce of oil of wintergeen, and up 
to eight ounces of cotton-seed oil. 

Third, a twenty or fifty per cent ointment of ichthyol, 
the base of which is lanolin. 

Fourth, a preparation consisting of one part of 
guaiacol and three parts of glycerin. 

Other external applications are methyl salicylate ; 
lead and opium wash ; Fuller's lotion (consisting of 
sodium carbonate, one ounce ; tincture opium, one 
ounce ; glycerin, three ounces ; water, twelve ounces) ; 
chloroform liniment; tincture of iodin ; sulphur pow- 
der ; and vinegar. 

Fever is treated the same as in other febrile dis- 
eases, by the application of cold in the form of sponges, 
packs, and baths. 

Delirium is quieted by hydrotherapeutic measures. 
It is important to remember that delirium may result 
from the exhibition of salicylic .compounds. A patient 
of the author's, seen for the first time at the end of 
the first week of the disease, had had no delirium. 
Within twelve hours after beginning salicylates the 
man became very delirious. The delirium ceased with 
the withdrawal of the salicylates but returned when 
the medication was again instituted. 



ACUTE ARTICULAR RHEUMATISM. 1 73 

Careful attention must be paid to the heart as this 
organ is often profoundly affected in rheumatism. 

Convalescence. — The patient is not to get out of 
bed until the temperature has been normal for a week> 
and not even then if any heart complications are pres- 
ent. The diet is to be gradually increased until full 
diet is resumed. Meats, especially the red ones, are 
to be but sparingly given. Special care must be taken 
to avoid exposure to cold and wet. Light massage of 
the joints and muscles is beneficial. 



CHAPTER XX. 
MALARIAL FEVER. 

Etiology. — The exciting cause of malarial fever 
is probably the Plasmodium of Laveran. This organ- 
ism is not a bacterium but one of the protozoa. 

Predisposing Causes. — The disease is especially ac- 
tive in the temperate and tropical zones : in swampy 
and marshy regions : along rivers, especiallv those 
streams which overflow their banks : in new agricul- 
tural districts and near large excavations. 

Poor surface drainage is one of the main factors in 
predisposing the disease. The most cases appear in 
Spring and Summer, especially after a prolonged dry 
season. The winds seem to carry the disease from 
place to place. 

Symptoms. — The disease may be preceded by pro- 
dromal symptoms as malaise, loss of appetite, suboc- 
cipital headache, feeling of uneasiness in the epigas- 
trium, nausea, and a desire to yawn. 

The paroxysm is divided into three stages ; namely, 
the cold stage, the hot stage, and the stage of sweat- 
ing. 

Cold Stage. — There is general chilliness, the patient 
shivers, the face becomes pinched, the lips blue, and 
a pronounced chill occurs, lasting from five to sixty 

i74 



MALARIAL FEVER. 



!75 



minutes or more. The surface of the body is pale 
and cold but the temperature is raised (103 F. to 
106 F.). The pulse is rapid, small, and hard. The 
urine is increased in amount. 

Hot Stage. — This stage develops in five to fifteen 
minutes after the former. Instead of chilliness or 
chills there is a feeling- of warmth, the formerly pale 
skin becomes flushed, the face congested. The pulse 
hitherto small and hard is now full and bounding. 
The headache is intense and throbbing. The urine 



DAY 
















hJJRj 


4- 8 12 


4 8 12 


4 8 tt 


4 6 


12 


4 8 


12 


4 


8 


12 


4 


8 


12 


4 


8 


12 


4 


8 


12 


4 


8 


12 


4 


8 


12 


4 


8 


12 




I0: 


























































107 
106 
105 
104 
103 
102 
101 
100 
99 
98 
97 


105 
104 
103 
102 
101 
10O 
99 
96 
97 







































































































































































































Fig. 15. — Temperature chart of intermittent malaria (tertian). 



becomes scanty in amount. The patient is very thirsty. 
The temperature varies but a fraction from that in 
the cold stage. Delirium is common. This stage may 
last from thirty minutes to five hours. 

Sweating Stage. — The pains and anxiety of the for- 
mer stages are relieved by the advent of this stage. 
Sweating usually begins on the forehead and extends 
over the whole body. The pain and feverishness are 



176 



FEVER NURSING. 



decreased and complete relief is ushered in by refresh- 
ing sleep. This stage lasts from one to three hours. 



DAi 
















HE 

10a 

137 


4 8 12 4 8 12 


4 6 12 


* 


8 12 


4 


8 12 


4 


a 


12 


4 


8 12 


4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


■08 
107 


IC5 
105 
104 
103 

:: 

101 

100 
99 

98 

97 
































K 

105 
'04 

103 












=^102 
= llOI 














no 
















98 


* 1 1 1 | | 1 












97 



Fig. 16. — Temperature chart of intermittent malaria (quotidian) 

The whole paroxysm lasts from two to fifteen hours. 
Throughout the paroxysm the spleen is enlarged and 



oay| 














WU8SJ4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 




108 1 j j 1 

107 1 ' | :■=•= 

106 [ ; 1 | 


























08 
107 

106 


'°5 \_}. \ }^=j= 
104- [ j j A; 
103 1— l i HH 

10? j ! f~\ 


























IC5 
104 
:03 
102 


100 1 / ■ 1 : 

99 / » 

9s,»-*, i 1 S 












; ; 1 ==!00 

.' j '' J =f=3 99 

.^^t^i—T^S, 93 


97J"-| | "I' | | ■ 














j ] i j^-J97 



Fig. 17- — Temperature chart of intermittent malaria (quartan), 



tender and the viscera are congested. Herpes of the 



MALARIAL FEVER. 



177 



lips are common in malaria, the tongue is coated, con- 
stipation or diarrhea may exist. 

Fever. — The temperature rises in the cold stage and 
continues high until the sweating begins, when it falls. 
The temperature rises with each paroxysm and the 
frequency depends on the character of the infection. 
In the tertian type the paroxysms occur every other 
day. In the quotidian they occur daily. In the quar- 
tan on the fourth day. There may be a double infec- 
tion of the same type or mixed infections of the vari- 
ous types. 



"DAY 
















mms 


4- 8 12 4 8 12 


4 8 12 4- 8 12 


4 8 12 4 8 12 


4 6 12 4 8 12 


4 8 12 4 8 12 


4 8 12 4 8 12 




103 




























































108 
107 
106 
105 
104 
103 
102 
101 
10 


10? 
106 
105 

104 
103 

so? 

101 
100 
99 
98 

V 
























































































9 J 
9^ 













































Fig. 18. — Temperature chart of remittent malaria. 

Varieties. — There are four principal forms of ma- 
laria: intermittent, remittent, pernicious, cachectic. 
The intermittent form is described above. 

Remittent form, also known as bilious remittent 
fever, estivo-autumnal fever, and irregular malaria. 

Symptoms. — Malaise and chilliness. The fever is 
irregular, rises gradually, and usually drops by lysis. 
12 



178 FEVER NURSING. 

The paroxysm is not well defined. The face is flushed, 
the conjunctivae are injected. Xausea, vomiting, and 
epigastric pain are very common. Jaundice occurs in 
many cases. Delirium is frequent. The general course 
resembles typhoid fever to a great degree. 

Pernicious Malaria. — This is a very grave form. 
There are three types, the algid, the comatose,, and the 
hemorrhagic forms. 

The Algid Form. — As the name would indicate, this 
form is characterized by the coldness and low tempera- 
ture. Vomiting is frequent, prostration is very great, 
the pulse is rapid, feeble and small; the temperature 
may be subnormal ; the urine is suppressed, very dark 
jaundice is characteristic, and collapse may follow an 
exhausting diarrhea. 

The Comatose Form. — The chill is of short duration 
or absent. The skin is hot, the temperature is high. 
The nervous symptoms are marked. The delirium is 
followed in many cases by coma and death, or the 
unconsciousness may last ten or twelve hours and then 
cease. A second paroxysm is generally fatal. 

The Hemorrhagic Form. — This form is character- 
ized by the tendency to hemorrhage from the mucous 
membranes and the kidneys. There are no febrile 
paroxysms, hematuria is common, jaundice is not as 
marked as in the algid form. 

Malarial Cachexia. — This is a chronic malarial in- 
toxication, caused by a continued progress of a simple 
form. It is characterized by its great anemia and 
chronic enlargement of the spleen. There is a tend- 
ency to bleeding from the mucous membrane, uterus, 



MALARIAL FEVER. 1 79 

and kidneys. The skin is sallow. Headaches are 
common and severe. 

Prognosis. — Always favorable in the simple in- 
termittent form, although chronic malarial cachexia 
may follow. Favorable in the remittent form. Always 
grave in the pernicious forms, especially in the algid 
type. 

Care and Management. — Malaria is transmitted 
by means of the mosquito, which acts as the interme- 
diary host. Thus it will be seen that if a region in- 
fected with malaria is freed of mosquitoes, the disease 
will gradually disappear. The breeding places of the 
mosquito are stagnant pools and slow flowing waters. 
The water found in road ditches, in old cans, in rain 
barrels, in tree stumps, in the angles of the boughs 
and the tree trunk, along the sides of slow-flowing 
creeks, forms an excellent field for the development of 
the larvae of the mosquito. 

All road ditches and puddles should be filled with 
earth to prevent the water from collecting. Rain bar- 
rels should be covered with very fine meshed netting. 
Holes in trees should be packed. Pools of large size 
should be treated with kerosene oil. This forms a film 
on the surface of the water, preventing the embryo 
mosquito from getting fresh air and therefore causing 
its death. 

Small fish in a stream, pond, or fountain will eat 
the larvae and thus prevent to a great extent the de- 
velopment of the mosquito in these waters. 

The house should be protected from the invasion 
of the mosquito by means of screens. Bed canopies 
are also useful barriers. 



l8o FEVER NURSING. 

General Management. — In the intermittent form of 
malaria the patient must be confined to bed during the 
paroxysm, but may be allowed to leave the bed between 
the attacks if he feel strong enough and object to re- 
maining in bed. In the remittent and pernicious forms 
absolute rest in bed is a necessity. 

The diet as in other febrile diseases is to consist 
mainly of milk and liquid foods. 

Of all drugs used in the treatment of this disease 
quinin holds the first place. This drug acts directly 
on the cause of the disease, the plasmodia, and destroys 
their vitality. The object of the treatment is to pre- 
vent future paroxysms and not to stop the paroxysm 
which is in progress, as this cannot be done. There 
are two methods of giving quinin, in one massive daily 
dose; and in small divided doses with a larger dose 
before the expected paroxysm. By the former method 
the toxic effects of the drug may be excited. 

As quinin is slow in absorption, the last dose should 
be given several hours before the oncoming attack. 

If a purge, as calomel, be given an hour before the 
administration of the quinin, this latter drug will act 
much more quickly and better. 

In some susceptible individuals the toxic effects of 
quinin, known as cinchonism, come on quickly and 
even after a comparatively small dose. The signs of 
this condition a re ringing in the ears, vertigo or diz- 
ziness, nausea, vomiting, fullness of the head, impaired 
vision, and at times deafness. 

During the cold stage the patient may be made 
much more comfortable by covering him well with 
blankets, placing hot-water bottles to the extremities, 



MALARIAL FEVER. l8l 

and giving hot drinks. If the chill be very severe, in- 
halations of chloroform or amyl nitrite will be of ser- 
vice. Atropin by hypodermic is useful. 

The hot stage is best treated by cool sponges or 
rubs. An ice-bag to the head is very grateful to the 
patient. 

In the sweating stage the patient is made more com- 
fortable by using such coverings as will easily absorb 
the moisture caused by perspiring. 

The remittent form is managed on the same plan, 
more or less, as in typhoid fever. Absolute rest in 
bed, liquid diet, attention to the bowels and tempera- 
ture. In case of tympanites, the turpentine stupes will 
be found useful. 

Vomiting, which is very frequently present in this 
form, must receive especial attention. Small pieces of 
ice by the mouth and a mustard paste to the epigas- 
trium are of benefit. 

The pernicious form as has been stated is very grave 
and needs vigorous treatment. The purpose of prime 
importance is the prevention of a second paroxysm. 
Quinin is given in enormous doses. Stimulants are 
to be freely administered. 

In the algid type the external application of heat 
is of prime importance. 



CHAPTER XXL 

ERYSIPELAS. 

Definition. — An acute, infectious fever character- 
ized by an acute inflammation of the skin and gen- 
eral symptoms of toxemia. 

Etiology. — The exciting cause of erysipelas is the 
streptococcus erysipelatis which is said to be identical 
with the streptococcus pyogenes. 

The germ gains entrance through some break in the 
continuity of the cutaneous or mucous surfaces. In 
cases of facial erysipelas the bacterium usually finds 
a portal of entrance in the nasal passages. 

Certain individuals seem particularly predisposed. 
Some women have recurrent attacks at the menstrual 
periods. Relapses and recurrences are liable. 

Symptoms. — Constitutional Rigors or chills gen- 
erally usher in the attack. Several days of malaise, 
frontal headache, and gastric disorders may precede 
the general signs. In twenty-four hours the local 
lesion is generally manifest. 

The temperature rapidly becomes high (104 R), 
the pulse rapid, prostration is more or less prominent. 
The tongue is dry. The urine is scant in amount, dark 
in color, of a high specific gravity, and contains albu- 
men. The bowels are usually constipated. Delirium 
is not uncommon. 

182 



ERYSIPELAS. 183 

Local. — A small inflamed area of a dusky red color 
is first seen. The local lesion is painful and tender 
and a sensation of tension is frequent. The area of 
inflammation has a prominent well defined margin. 
There is more or less swelling which pits on pressure. 
The lesion spreads from the periphery while healing 
in the center. Migration is rapid and a great portion 
of the body may become affected. 

In facial erysipelas the eyelids and surrounding tis- 
sues may become greatly swollen, and the eyes closed. 
The whole face is sometimes swollen beyond recog- 
nition. Blebs or large blisters are of frequent occur- 
rence on the face, eyelids, and forehead. In four or 
five days the redness begins to fade and the swelling 
to decrease, and unless recrudescence occur the process 
is at an end. 

Complications. — Pneumonia, pleurisy, pericardii 
tis, and endocarditis are not uncommon. Nephritis 
is a very serious complication, as also is septicemia. 

Prognosis. — A simple case usually results in re- 
covery in about two weeks. The prognosis is less 
favorable in those individuals suffering from other 
diseases, as nephritis, and in alcoholics and during ths 
puerperal state. 

Chronic swelling of the parts and eczema are com- 
mon sequelae. 

Care and Management. — This disease is of a gen- 
eral character and not simply a local disease of the 
skin, as it was formerly thought to be. 

Complete isolation of the patient is the first requisite. 
A very mild case of facial erysipelas may excite in a 
susceptible individual a most severe and fulminating 



J&4 FEVER NURSING. 

form of the disease. Young children are especially 
likely to contract the disease, as are also women in the 
parturient stage. Dr. Goodell believed there is a rela- 
tionship between puerperal sepsis and erysipelas. 

The nurse or attendants should not come in contact 
with anyone suffering with an ulcer or an open wound 
of any kind, as these persons are very easily infected 
with erysipelas. 

A nurse who has been attending a patient ill with 
erysipelas should under no circumstances undertake 
the care of a parturient woman until she (the nurse) 
is absolutely free from the danger of carrying infec- 
tion. It will be safe to do pure medical nursing before 
entering surgical or obstetric service. 

Rest in bed is necessary in the more severe cases, as 
the disease is very depressing. In the mild cases the 
patient may be up and around for part of the day. 

The diet is of great importance and should be con- 
centrated and very nourishing, as milk, gruels, eggs, 
etc. First because the disease is very depressing and 
prostrating, and secondly because recovery depends on 
the vitality of the patient, which can be kept in a good 
state only by providing the most nutritious foods. 

The bowels should be kept open by saline laxatives 
and enemata. 

Headache, which is often very trying, is relieved by 
the application of an ice-bag to the head. 

Fever, if high, is lowered by means of sponges, 
packs, and baths. 

Sleeplessness is overcome by a glass of hot milk, to- 
gether with a hot foot bath and an ice-bag to the head. 

The kidneys, which are liable to be affected in this 



ERYSIPELAS. 1 85 

disease, should be kept active by giving the patient 
plenty of drinking water. 

The heart should be carefully watched. 

Of internal medicines the tincture of chlorid of iron, 
and some salt of quinin are most frequently given. 
These are simply mentioned in passing. 

Antistreptococcic serum is much praised by eminent 
authorities. 

We now come to local measures. These are mani- 
fold. Ichthyol probably holds the first place. Of all 
local applicants I have found it the most beneficial. 
It may be applied in one of several ways : as an oint- 
ment of twenty-five per cent strength, or dissolved in 
water or glycerin ( I to 4) . 

A most excellent method is by combining it with 
collodion and painting it over the lesions. This meth- 
od causes exclusion of air, which is very important, 
and also keeps the medicament in contact with the 
lesion. 

One important point to be remembered in the use of 
ichthyol is that it should be freely applied. 

Other applicants are resorcin, which may be used 
alone or combined with ichthyol ; solution of lead ace- 
tate ; carbolic acid, one to twenty ; bichlorid of mer- 
cury, one to one thousand ; tincture of iodin ; solution 
of boric acid ; silver nitrate in a solution of one to three. 

If the lesion be on one of the extremities, adhesive 
straps applied around the limb above and below the 
site are said to prevent its extension. 

If the case be one of facial erysipelas, attention 
should be given to the nasal and pharyngeal cavities 
and to the mouth. These should be cleansed by anti- 



1 86 FEVER NURSING. 

septic solutions, as sprays, douches, and gargles. A 
one-to-eight solution of hydrogen peroxid is very good. 

All dressings should be burned as soon as removed. 

The nurse should scrub her hands thoroughly and 
immerse them in a one to one-thousand solution of 
bichlorid of mercury after each dressing and before 
eating her meals. 

The patient should have separate towels, washcloths, 
and eating utensils. 

After convalescence cheap articles of clothing should 
be burned and other pieces may be disinfected with the 
room, as described under Scarlet Fever. 



CHAPTER XXII. 

SEPTICEMIA, TOXEMIA, AND PYEMIA. 

Definitions. — These terms are being constantly 
confused and interchanged. Each is a distinct condi- 
tion and it is important that they be thoroughly under- 
stood. I will endeavor to define each in simple and 
concise form. 

Toxemia is a morbid condition characterized by the 
presence of toxins in the blood. An example is diph- 
theria. In this disease the local lesion as a rule is on 
one of the mucous membranes of the upper respi- 
ratory tract. The germs themselves rarely leave the 
local site, but the toxins or poisonous products which 
the bacteria form are absorbed and enter the blood; 
then they are carried throughout the body and give 
rise to general constitutional symptoms. 

Septicemia is a morbid condition characterized by 
the presence of bacteria and their toxins in the blood. 
Typhoid fever is an example of a septicemic condition. 
Here we find the typhoid bacillus in the circulation. 

Pyemia is a morbid condition characterized by the 
presence of pus-producing germs in the blood, together 
with the formation of secondary purulent deposits or 
metastatic abscesses. 

Sapremia is a morbid condition characterized by the 
presence in the blood of the products of decay or putre- 

187 



I«8 FEVER NURSING. 

faction. For example: after a partial ectopic mpture 
a clot of blood will be found in the pelvis. This may 
soon be invaded by micro-organisms and decompose. 
The products when absorbed give rise to toxic symp- 
toms. 

All the conditions described above are referred to by 
the laity as blood poisonings, which in reality they are. 

Etiology. — These conditions may be caused by 
any bacterium. Toxemias usually occur in the acute 
infectious diseases. Pyemia may follow any operation, 
being due to infection by pus-producing organisms, as 
the staphylococci and streptococci. Sapremia is fre- 
quent in incomplete abortion, in retention of the pla- 
centa in whole or in part, or of parts of the mem- 
branes ; also in conditions accompanied by extensive 
sloughs. 

Symptoms, — Toxemia. The general symptoms of 
toxemia are chill or chilly sensations, fever, headache, 
malaise, loss of appetite, restlessness, prostration, rapid 
pulse, and in pronounced cases delirium, coma, nausea, 
vomiting, and diarrhea. 

Septicemia. — The symptoms are similar to those of 
toxemia but are much more severe. The chill may be 
pronounced, the fever is at first moderate but soon 
becomes high and runs a very irregular course with 
daily remissions or intermissions ; the pulse becomes 
very rapid and feeble. Nausea and vomiting are not 
infrequent. Nervous symptoms are common : delir- 
ium, apathy, and convulsions (in the young). A very 
characteristic occurrence is the enlargement of the 
spleen and the lymph glands. 

Pyemia. — This condition in most instances is ush- 



SEPTICEMIA, TOXEMIA, AND PYEMIA. 



189 



ered in by a pronounced chill. The chills recur fre- 
quently, in some cases daily and more or less often. 
With the chill there is a rapid and high rise of tem- 
perature. These paroxysms recur. The temperature 
may reach 103 ° F. to 105 ° F. and is followed by a 
more or less profuse sweat, after which the tempera- 
ture is again low. These phenomena resemble very 
much those of malaria. 



DAY 
















HtWB 


4 8 12 


4- 8 12 

1 1 


4 8 


12 4 8 


12 


4 


8 


12 


4 


8 


12 


4 


8 


12 


4 


8 


12 


4 


8 


12 


4 


8 


12 


4 


8 


12 


4 


8 


12 




10? 

!06 

ioT 

104 
103 
102 
101 
100 
99 

?■-: 
97 
































































107 
106 
105 






























































104 
103 
102 
101 
100 
99 
98 
97 







































































































Fig. 19- — Temperature chart of pyemia. 

The general symptoms are general malaise, head- 
ache, loss of appetite, nausea, and vomiting. As the 
disease progresses prostration becomes very marked, 
anemia develops, the skin takes on a sallow hue, diar- 
rhea may be exhausting, and the patient may develop 
a low typhoid condition with delirium, subsultus ten- 
dinum, etc. 

Abscesses may form in any part of the body: in 
the joints, subcutaneous tissues, or in the viscera. 

Care and Management. — The outcome of these 
diseases depends largely on the nursing. Their course 



I90 FEVER NURSING. 

is so irregular and varied, their character is so general 
that the treatment consists principally of supportive 
and expectant measures. 

Support of the strength of the patient is the most 
important requisite. These diseases run their course 
and recovery depends on the vitality of the patient. 

The patient's vigor is conserved best by absolute 
rest in bed and a most nourishing diet. Milk will form 
the basis of the diet and is to be supplemented with 
gruels, eggs in soft form, albumin water, broths, pre- 
digested forms of beef, etc. 

Symptoms should be alleviated as they arise. 

Fever, if it become excessive, is treated by the appli- 
cation of tepid or cool water in the form of sponges, 
packs or baths. 

Delirium, which may occur, is also quieted by these 
same means. 

Vomiting may be so severe that no food or medicine 
can be retained in the stomach. In these instances 
medicine must be given hypodermically if possible or 
by rectum. Nutritive enemata should be instituted. 
Oftentimes a mustard paste applied to the epigastrium 
will stop the vomiting. Washing out the stomach is 
of good service in selected cases. 

Szveating, which is common, especially in pyemic 
cases may be lessened by bathing the body with alcohol, 
or a combination of alum one ounce, alcohol one-half 
ounce, and water two pints. 

Stimulation is of frequent necessity. For general 
stimulation of the heart digitalis and strychnin by 
mouth are of greatest value. When rapid stimulation 
is necessary hypodermic injections of strychnin, ether, 



SEPTICEMIA, TOXEMIA, AND PYEMIA. 191 

or spirits fermenti are indicated; or give by mouth 
dram doses of aromatic spirits of ammonia or com- 
pound spirits of ether. The use of camphor dissolved 
in sterile olive oil is an excellent stimulant. It should 
be given by hypodermic and in one-grain doses. 

Elimination of the toxins is of vital importance and 
should be encouraged by one or all of the following 
methods. 

By the Bowels. — The bowels should be kept open 
by means of calomel, or better, by saline cathartics, as 
magnesium sulphate (Epsom salts), or sodium and 
potassium tartrate. 

In some cases of pyemia a colliquative diarrhea oc- 
curs. This should not be checked at once as it is one 
of nature's ways of expelling toxins. A large quantity 
of the toxins are excreted into the bowels ; therefore, 
by emptying the intestines we get rid of a large amount 
of toxins. 

Washing out the colon is of excellent service. I 
have found a most admirable method in the use of the 
Kemp double rectal irrigating tube, which allows a cir- 
culation of water to take place in the rectum and colon. 
The inflow tube is connected with the source of water, 
as a fountain bag or an irrigating jar; the outflow 
tube is connected with a large tub by means of rubber 
tubing. Normal saline solution is used in large quan- 
tities. In one case I used as much as fifty gallons of 
the solution. 

The temperature of the solution used in colonic irri- 
gation should be of such a degree that when it reaches 
the colon it is not above 99 F. If a long tube be used 
on the fountain bag, the temperature of the solution 



192 FEVER NURSING. 

may be 104" F. If a short tube be used, then ioo° F. 
or ioi c F. is enough. If the temperature of solutions, 
when large quantities are used, be too high, there is a 
liability of producing heat stroke, or of causing ex- 
cessive fever in the patient. 

By the Skin. — Sweating is promoted by hot drinks, 
by wrapping the patient in hot dry or wet blankets, or 
by introducing heat under the bed clothing by means 
of a hot-air apparatus. Hypodermoclysis of normal 
saline solution is very useful. 

By the Kidneys. — Give the patient plenty of water 
to drink. Encourage the flow of urine with the spirits 
of sweet niter. Hypodermoclysis of normal saline so- 
lution is of especial value in eliminating the toxins by 
the urine. They should be given as regularly as any 
medicine. One case of severe sepsis under by care 
was saved by the systematic giving of normal salt solu- 
tion under the skin. 

Use of Antitoxin. — Marmorek in 1895 announced 
the discovery of an antistreptococcic serum and also re- 
ported its successful use in many septic cases. Whether 
it be of any real value in general infections is yet to 
be ascertained. It is given in the same way as the 
diphtheria antitoxin, in doses of ten cubic centimeters. 

The use of organic silver salts I think will, in the 
future, partially solve the treatment of general infec- 
tious processes. 



PART IIL 

ADDENDA. 

CHAPTER XXIII. 

ANTITOXINS AND BACTERIAL VACCINES. 

Antitoxins. 

One of the greatest, if not the greatest advance in 
medical science during the last decade, was the pro- 
duction of substances which counteract the destruc- 
tiveness of bacterial poisons. 

Closely connected with the subject of antitoxins is 
that of immunity. 

Immunity may be complete or partial, natural or 
acquired, temporary or permanent. 

Natural immunity for the various infectious diseases 
is enjoyed by not a small number of persons. 

Acquired immunity is obtained in various ways : By 
the injection of antitoxins ; by modified virus and vac- 
cines, as in smallpox; by the gradual injections of tox- 
ins; by the gradual injection of virulent cultures; by 
a previous attack of the disease. 

All the above means bring about the same ultimate 
result, a stimulation of the body cells to form certain 
antagonistic bodies or antitoxins. 

iWhen bacteria gain entrance to the human body, 
they begin to multiply in number and form certain 
13 i 93 



194 FEVER NURSING. 

poisonous substances known as toxins, and these cir- 
culate in the blood and cause general "blood poison- 
ing" or toxemia, It is this generalization that causes 
the seriousness of the disease. The germs themselves, 
as a rule, remain in a local place. In typhoid fever 
the germs find their resting place in the coats of the 
bowels ; in pneumonia, in the lungs ; in diphtheria, on 
the mucous membranes of the larynx, pharynx, or 
nose. If the germs also enter the circulation and are 
scattered far and wide, the condition is known as 
septicemia. If the germs after being scattered about 
the body form abscesses, the condition is called pyemia 
and the abscesses are designated metastatic abscesses. 
While mentioning the different forms of "blood poi- 
soning" I will call attention to a fourth form, known 
as sapremia. This is caused by a circulation in the 
blood of putrefactive material. A good example is 
found after labor and results from a retention of all 
or part of the placenta. The part that remains in the 
uterus will soon decompose and this material, when 
absorbed, will cause a certain septic condition known 
as sapremia. 

The toxins mentioned above, when circulating in the 
blood, act upon the cells of the body and cause the 
appearance of symptoms characteristic of the disease. 
The body cells on the other hand, as soon as harassed 
by these toxins are stimulated to resistance, which is 
effected by the formation of bodies which antagonize 
the toxins, and are known as antitoxins. 

If the toxins be weak or small in quantity, the body 
cells may overcome their deleterious action, and the 
individual survives. If the toxins be very virulent and 



ANTITOXINS. 195 

the resistance of the person be low, then the bacteria 
are the victors and the individual perishes. 

If the toxins be virulent and the resistance of the 
person be great, the battle is more evenly balanced 
and the victory may be won by either side. First the 
laurels sway to one side and then to the other. It is 
in this type where the reinforcements sent by the phy- 
sician will aid the patient in conquering. 

As said above when toxins enter the body the cells 
of the body at once begin to produce defensive agents 
in the form of antitoxins. Before discussing the pro- 
duction of antitoxins a few definitions are necessary. 

A toxin unit is ten times the amount of toxin re- 
quired to kill in twenty-four hours, a guinea pig weigh- 
ing two hundred and fifty grams. 

An antitoxin unit is ten times the amount of anti- 
toxin required to neutralize one toxin unit. 

Production of Antitoxin. — In discussing the pro- 
duction of antitoxins I will follow the procedure used 
in producing diphtheria antitoxin. 

A culture is made by planting live diphtheria bacilli 
in sterile bouillon and this is placed in a warm room 
to grow from four to seven days. The result is what 
is called a virulent culture. This culture is then at- 
tenuated by adding to it carbolic acid until it becomes 
a five-tenth per cent solution. It is then filtered 
through stone ware, which removes the germs and 
foreign matter and a clear solution results containing 
the toxins. This toxin solution is tested as to its 
strength by the inoculation of guinea pigs. The 
strength having been determined, it is ready for use. 

For the production of antitoxin the horse is used 



I96 FEVER NURSING. 

because of the large amount of blood it contains, be- 
cause of its more or less immunity, and because of its 
easy management. 

Into the muscles of the horse's neck is injected ten 
to twenty toxin units of toxin. In twenty-four to 
forty-eight hours the area will become red, swollen, and 
hot. The temperature becomes high and signs of de- 
pression ensue. After two or three days these symp- 
toms disappear when another and larger dose of toxin 
is injected, and so on until enormous doses of this 
toxin are given. At the end of one to three months 
the serum of the horse's blood will be rich in antitoxin. 

Test bleedings are made from time to time to deter- 
mine the amount of antitoxin present and when suffi- 
cient is present the final bleedings are made every few 
days until twenty or more liters of blood are removed 
from the horse. About one-half of the bleeding will 
be serum which is collected in sterile vessels and is 
prepared to be sold as antitoxin. 

The horse, after a short rest, is again injected with 
toxins. 

If when the toxins are injected, there be antitoxin 
injected at the same time, the dose of toxin may be 
greater and the horse is immunized very rapidly, each 
successive injection containing less antitoxin and more 
toxin. 

Varieties of Antitoxins. — Of all antitoxins, great- 
est success has followed the use of diphtheria antitoxin. 
The antitoxin should be administered as early as pos- 
sible and in large, frequently-repeated doses. Anti- 
toxin itself is not poisonous but the serum may cause 
disturbing symptoms. 



BACTERIAL VACCINES. 197 

The average curative dose is three thousand units, 
and for immunizing purposes, at least five hundred 
units should he given. The immunity is temporary, 
lasting from four to six weeks. (H. Biggs.) 

Other antitoxins which have been produced with 
greater or less success are those against the streptococ- 
cus, tetanus bacillus, typhoid bacillus, bacillus of bu- 
bonic plague, yellow fever, pneumonia, cholera, etc. 

Bacterial Vaccines. 

Dr. Wright, of London, has been foremost in the 
introduction into medicine of the use of bacterial vac- 
cines. These vaccines consist of killed cultures of 
bacteria, and, when injected into man, aid the body to 
overcome the action of the specific infection by stimu- 
lating the cells to increased protective energy. The 
immunity conferred by the use of vaccines differs from 
that of antitoxins in that the latter is passive, whereas 
the former is active. 

The vaccine employed depends on the nature of the 
infection. The more common bacterial vaccines and 
the infections for which they are used are as follows : 
Staphylococcus vaccine (erysipelas, scarlet fever and 
cellulitis), pneumococcus vaccine (empyema, cystitis), 
gonococcus vaccine (gonorrhea, ophthalmia neona- 
torum, gonorrheal arthritis) ; other vaccines are those 
of typhoid bacteria and the tuberculines. 

The vaccine is administered by means of a hypo- 
dermic syringe ; the initial dose varies from 5,000,000 
to 1,000,000,000 bacteria. After injection, there occur 
certain phases or reactions, known as the negative and 



198 FEVER NURSING. 

positive phases. The negative phase is a condition in 
which the opsonins of the blood are decreased, and is 
clinically noted by the depressed state of the patient. 
The positive phase is marked by an increase of the 
opsonins in the blood, with general improvement of the 
patient's condition. 



CHAPTER XXIV. 
BACTERIA. 

In this chapter only such microorganisms as are 
concerned in the diseases discussed in this book will be 
considered. 

A bacterium is a microorganism of vegetable origin. 
Bacteria cause changes in the substance in which they 
grow and form new products in themselves which they 
retain or throw out. 

Classification. — Bacteria are classified in several 
ways. 

Parasites and saprophytes; the former are called 
such because they subsist on living organic tissue, the 
latter live on dead material. 

Pathogenic and non-pathogenic; the former are the 
cause of disease and the latter do not cause disease. 

Aerobic, those which require oxygen to maintain 
life. Non-aerobic, those which live without oxygen. 
Facultative, those which can grow with or without 
oxygen. 

Micrococci are bacteria consisting of spheric bodies 
which may vary in their arrangement. If the spheric 
bodies are in the form of a chain, then that micrococcus 
is known as a streptococcus; if in the form of a bunch 
of grapes, that is, grouped, it is a staphylococcus; if 
in pairs, then diplococcus; if in series of fours, then 
tetrads; if in cubic form, then sarcince. 

199 



200 FEVER NURSING. 

Bacilli are bacteria which appear as small rod-shaped 
bodies. 

Spirilla are bacteria which are curved. 

Growth. — Bacteria multiply by direct division, in 
which the bacterium is divided into two segments and 
each of these grow as separate individuals. Or they 
multiply by what is known as spore formation, in 
which small glistening bodies appear within the bac- 
terium, which are later set free and become indepen- 
dent bacteria. 

Nutrition. — A medium for bacterial growth must 
contain nitrogen, which is supplied by albumen ; car- 
bon, which is supplied by sugar ; and the presence of 
moisture. The medium also should be neutral or 
slightly alkaline in reaction, and be kept at a tempera- 
ture about 98 ° F. Bacteria will adapt themselves to 
the soil and temperature to which they are subjected. 

Media for the growth of bacteria are numerous; 
among the more common are the following: 

Bouillon, which is made by compressing cold beef, 
and adding common salt and peptone to the juice. This 
juice is then boiled and filtered. 

Gelatin is made by adding ten per cent of gelatin 
to the bouillon. 

Agar-agar, made by adding one per cent of agar- 
agar to bouillon. Agar-agar, also known as Japanese 
gelatin, is a vegetable gelatin derived from a variety of 
seaweed growing along the coast of Japan. 

Other forms of media are blood serum, glucose, po- 
tato, milk, blood and peptone solution. 

Micrococci. — Staphylococcus Pyogenes Aureus, 
This is the most common bacterium of a pathogenic 



PLATE I. 




Various Forms of Microorganisms. 

I, Streptococci ; 2, Staphylococci; 3, Diplococci ; 4, Tetracocci 

5, Spirilla ; 6, Bacilli ; 7, Bacilli with spores. 



BACTERIA. 20 1 

nature found in the body. It is the cause of the ma- 
jority of the circumscribed purulent inflammations. It 
derives its name from the fact that it is composed of 
spheric bodies arranged in groups (staphylococcus), 
that its presence in the body is accompanied by the 
production of pus (pyogenes), and that if cultivated 
on media it produces colonies with an orange color 
(aureus). 

Other pathogenic staphylococci are the staphylococ- 
cus pyogenes albus and staphylococcus pyogenes cit- 
reus. 

Streptococcus Pyogenes. — This is also a common 
microorganism and is the cause of most of the diffuse 
purulent inflammations. This bacterium is the cause 
of erysipelas. The secondary or mixed infections in 
pneumonia, tuberculosis, typhoid fever, and diphtheria 
are due to the streptococcus pyogenes in a majority of 
cases. 

Pneumococcus. — This germ is the cause of lobar 
pneumonia. The pneumococcus is lance-shaped and 
surrounded by a capsule. The coccus is very sensitive 
to light, heat, and to germicidal solutions. 

The pneumococcus is not only the cause of lobar 
pneumonia, but may also be the exciting agent of men- 
ingitis, peritonitis, pleurisy, pericarditis, endocarditis, 
and otitis media. 

Diplococcus Intracellular is Meningitidis. — This bac- 
terium is the cause of cerebrospinal meningitis. The 
germ is composed of two spheric bodies and is usually 
found situated in the pus cells ; hence its name. 

Bacilli. — Typhoid bacillus was first described by 
Koch and Eberth. The bacilli occur as small, slender, 



202 FEVER NURSING. 

rod-shaped bodies. They do not stain readily and in- 
oculations of the culture into animals are unsatisfac- 
tory as to results. 

The Widal Reaction. — If a drop of a typhoid 
bouillon culture be placed as a hanging drop on a glass 
slide and be examined under the microscope with an 
oil-immersion lens, the typhoid bacilli will be seen as 
small, rod-like bodies moving and wriggling about. 
If to this drop of culture be added some diluted serum 
obtained from a person supposed to be suffering from 
typhoid fever, the bacilli in a short time will become 
quiet and gather in groups if the person have typhoid 
fever. If the person be not afflicted with this disease, 
the movements of the typhoid bacilli are not altered by 
adding the serum to the culture drop. 

The typhoid bacilli are eliminated from the body of 
the individual especially by the bowel movements and 
the urine. 

Influenza bacillus or the bacillus of Pfeiffer is the 
exciting cause of influenza. The germ is very small 
and can be grown only in the presence of hemoglobin. 
It may persist in the nasal and pharyngeal cavities for 
months after the patient has recovered from the dis- 
ease. 

Outside of the human body this germ has but little 
vitality ; it dies in a few hours and cannot live in dried 
sputum. 

Diphtheria bacillus is also called the Klebs-Loffler 
bacillus from the men who first described it. The bacil- 
lus is irregular in its outline, occurring as straight or 
curved rodlike bodies with clubbed ends. They are 
found in diphtheria on the surface of the affected mu- 



PLATE II. 




Bacillus pneumoniae, (X 800) 
", as seen in sputum. 




Bacillus influenzae in nasal secre- 
tion, (x 1000). 





Bacillus typhosus, a, ordinary 
form ( X 1000) ; b, flagellate 
form (X 1500). 



Micrococcus meningitidis 
cerebrospinalis, (X 1000). 




Bacillus tuberculosis; rt ,(Xiooo)- 
b, ramified or branching form.' 



BACTERIA. 203 

cous merrurane. They here form certain toxins which 
are absorbed and cause the general symptoms of a 
toxemia. Locally the bacilli cause a death and lique- 
faction necrosis of the superficial layers of the mucous 
membrane, forming a false or pseudomembrane. 

To combat the toxins of this bacillus a substance 
known as antitoxin has been found. (See Chapter 
XXIII). 

Tubercle Bacillus. — This bacillus occurs as small 
slender rods slightly bent or curved. They do not 
produce spores and grow with difficulty on media. 
They are very resistant to outside influences and will 
live for a great length of time in dried sputum. 

Tuberculin. — This substance when injected into a 
person will produce a certain reaction and is of diag- 
nostic value. The reaction is local and general. The 
local reaction consists of redness, swelling, and tender- 
ness ; the general reaction consists of a rise of temper- 
ature, general malaise, pain in the back, head and legs, 
nausea and vomiting, and at times a diffuse eruption. 

Tuberculin is prepared by taking a five-weeks' gly- 
cerin-broth culture of tubercle bacilli and evaporating 
it to one-tenth of its original volume, and filtering. 

The test is made by injecting into the person one- 
half milligram of tuberculin. In twelve hours the re- 
actions discussed above will appear. If no reaction 
occur, the test should be repeated in a few days, using 
more of the tuberculin. The usual place to give the 
injection is in the skin between the scapulae. 



CHAPTER XXV. 
URINE AND ITS EXAMINATION. 

Urinalaysis is one of the most positive methods for 
determining the presence of many important abnor- 
malities of the human organism. It is too frequently 
ignored by the medical man, or it is rapidly and im- 
properly conducted, therefore valueless and misleading 
It is important that every nurse should be thoroughly 
acquainted with physiological and pathological forms 
of urine, regarding its properties and constituents. 

Collection of Urine. — The urine to be preferred for 
examination is a four-ounce specimen of a twenty-four- 
hour collection. A statement of the amount of urine 
passed by the patient in the given twenty-four hours 
should accompany the specimen. If it is impossible to 
obtain a twenty-four-hour specimen, then the first urine 
voided in the morning is the next to be preferred. 

Urine for examination should be collected in an 
absolutely clean vessel and protected with a covering. 

We will now consider the properties of urine. 

Properties. 

Quantity. — Normal. The amount of urine voided in 
twenty-four hours varies considerably according to the 

204 



URINE AND ITS EXAMINATION. 205 

season, the amount of liquid taken, the profuseness of 
sweat, etc. From forty to sixty ounces are normal. 

It is increased in cold weather ; when the amount of 
water ingested is large ; in constipation, and by use of 
diuretics. It is decreased in warm weather ; when the 
amount of water taken is small; and when sweating 
is profuse. 

Increased (polyuria) in diabetes mellitus; diabetes 
insipidus ; chronic interstitial nephritis ; hysteria, 
cardiac hypertrophy; after epilpetic attacks, and 
during convalescence from typhoid fever and pneu- 
monia, and nervous excitement. 

Decreased (oliguria) in fevers; acute nephritis 
(three to six ounces) ; chronic parenchymatous 
nephritis ; cardiac failure ; diarrheal diseases ; anemia, 
emphysema ; shock and collapse ; the administration of 
drugs, as turpentine, cantharides, digitalis and ether 
(inhalation). 

Color. — Normal. Urine is, physiologically, of a light 
amber color and clear, but its color varies with the 
amount of urine voided. 

Abnormal. — Pink cloudiness is due to an excess of 
amorphous urates. 

White or yellow haziness may be produced by an 
excess of phosphate or the presence of mucus or pus. 

Dark amber, in diseases with decreased urine, as 
fevers, acute nephritis. 

Milky urine is due to the presence of chyle, and the 
condition is termed chyluria. 

Red-brown, or what may be appropriately called 
beef -brine, urine is due to the presence of blood, and 
is known as hematuria. It occurs in acute nephritis, 



206 FEVER NURSING. 

renal injury, renal calculosis, cystitis, stone in bladder, 
etc., and during the administration of turpentine, can- 
tharides and urotropin, in toxic doses. 

Goldcii-broiK.il urine results from the presence of 
bile coloring matter, and occurs in obstructive jaundice, 
and the condition is called biluria or choluria. 

Black or greenish brown coloration follows poison- 
ing from phenol derivatives, as carbolic acid, creosote, 
lysol and tar. 

Yellow urine is frequent after the administration of 
senna, santonin, picric acid. 

Blue or green urine follows the medicinal use of 
methylene blue. The patient should always be in- 
formed of this change of color. 

Red urine is due to the presence of hemoglobin, and 
the condition is termed hemoglobinuria. Hemoglobin 
occurs in the urine in scurvy, pernicious anemia, ma- 
laria, and after poisoning by trional, potassium chlorate 
and toxic mushrooms. The urine is bright red after 
the administration of logwood and fuchsin. 

Pale urine occurs in diseases characterized by poly- 
uria, as hysteria, diabetes, chronic interstitial nephritis, 
and at the crisis of febrile disorders. 

Odor. — Normal. Not much can be said of the odor 
of urine, except that it is characteristic and urinous. 

Abnormal. — Certain drugs and foods alter the odor 
of the urine, as asparagus, copaiba, valerian, musk and 
asafoetida. 

Sweetish odor of the urine occurs in diabetes 
mellitus. 

Violet-like odor follows the administration of tur- 
pentine, 



URINE AND ITS EXAMINATION. 207 

Ammoniac odor may be present when the urine is 
voided, or may develop soon after being passed. It 
occurs in certain types of cystitis. 

Fecal odor to the urine may be due to the presence 
of material which has escaped from the bowel into the 
bladder through a fistula. A similar odor is due to 
decomposing pus in the bladder. 

Reaction. — Normal urine has a slightly acid or neu- 
tral reaction. 

Abnormal. 

Hyperacid. — Urine is excessively acid in leucemia, 
rheumatism, lithiasis and chronic nephritis. 

Alkaline urine occurs in some forms of cystitis, in 
nervous dypepsia, cachectic conditions, and after ad- 
ministering certain drugs, as citrates, tartrates and 
bicarbonates. 

Specific Gravity, or Density. — By the specific 
gravity of urine we mean the weight of a certain 
amount of urine as compared to the weight of a like 
quantity of distilled water at a certain temperature. 
This can very easily be computed by the use of a simple 
instrument known as an urinometer. 

Normal. — The density of urine voided by a healthy 
individual varies between 1015 and 1025. 

Higher. — The gravity is higher when the amount of 
urine voided is decreased. (See Quantity.) 

Lower. — The gravity is lower when a large amount 
of urine is passed. 

Abnormal. 

High in diabetes mellitus (1070), acute nephritis, 
chronic parenchymatous nephritis, febrile conditions, 
diarrheal disorders and shock. 



208 FEVER NURSING. 

Low in diabetes insipidus, chronic interstitial ne- 
phritis, hysteria (ioooj. 

Constituents. 

Normal. — Urine is a watery fluid, holding in solu- 
tion certain salts, foremost of which are urea, uric 
acid and urates, phosphates, chlorides, sulphates and 
oxalates. 

Urea is one of the most important constituents of 
normal urine. It is freely soluble in water, hence never 
appears as a sediment. Urea is generally present in 
urine to the amount of 2 per cent. The daily output 
of urea can be easily computed by multiplying the 
quantity of urine voided in twenty-four hours by the 
percentage of urea, and averages 500 grains. Urea is 
increased after meals rich in nitrogenous food and 
after drinking large quantities of water ; it is decreased 
when the amount of food taken is small, when the 
bowels are loose, and when sweating is profuse. 

The excretion of urea is increased in fevers, diabetes, 
malaria, anemia, and after the crisis of pneumonia. It 
is diminished in all forms of nephritis, uremia, eclamp- 
sia, cachexia, rheumatism and nervous disorders. 

The estimation of urea will seldom be required of 
the nurse. For description of the method, consult 
some work on physiological chemistry. 

Uric Acid and Urates are present in the urine in 
small quantities. They are increased in fevers, tuber- 
culosis, gout, rheumatism, leucemia, diabetes and 
rickets. After the excessive use of milk and certain 
drugs, as mercury, salicylates and colchicum, the 
amount of uric acid excreted is increased. 



URINE AND ITS EXAMINATION. 200, 

It is diminished in anemia, nephritis, and after the 
use of iodides, lithium salts, sodium carbonate and 
chloride. 

Chlorids. — The chlorids in the urine are increased 
in malaria, diabetes and nephritis ; are decreased in 
pneumonia, rheumatism and some fevers. 

The excretion of phosphates is increased in nervous 
disorders. 

Abnormal. — The more important pathological con- 
stituents of urine are albumin, sugar, bile blood, pus, 
mucus and acetone. 

Albumin may be said to never occur in the urine 
normally, and is usually indicative of some patholog- 
ical change. The condition is known as albuminuria, 
and is met with in all forms of nephritis, especially the 
acute and chronic parenchymatous types ; in febrile 
conditions, especially erysipelas, scarlet fever and diph- 
theria ; in anemia, Grave's disease and leucemia ; in 
cardiac disease, emphysema, cirrhosis of the liver, and 
after the toxic use of certain drugs, as lead, mercury, 
turpentine, cantharides and ether. 

The tests for the presence of albumin in urine are 
manifold. We will consider only three, which are 
simple and at the same time accurate : Nitric acid test, 
heat and nitric acid test, potassium ferrocyanide and 
acetic acid. 

Before testing urine for albumin there are two 
necessary requisites: The urine should be clear and 
of an acid reaction. If the urine is not clear, it must 
be filtered ; if not acid, add dilute acetic acid until the 
specimen is slightly acid. 

Heat and Nitric Acid Test. — Fill a test tube three- 
14 



2IO FEVER NURSING. 

quarters full with the urine to be examined ; take hold 
of the bottom of the tube and hold diagonally in 
the flame of an alcohol lamp, or bunsen gas burner, 
so that the uppermost part of the urine is heated; 
allow it to boil for a moment. If no cloudiness or 
coagulum appear in the urine when heated, then 
albumin is not present. If a cloudiness does appear, 
it may or may not be indicative of albumin. This 
is positively established by adding to the heated urine 
a few drops of strong nitric acid, when the white cloud 
will disappear if not due to albumin (but phosphates), 
but if due to albumin, the cloudiness does not dis- 
appear, but may increase. 

Cold Nitric Acid Test. — Place in a test tube pure 
nitric acid (about two drams), and then with a fine 
glass tube allow some of the suspected urine to gently 
flow upon the surface of the acid. If albumin be 
present, a ring of white coagulum will form at the 
point of contact of the fluids. 

Potassium Ferrocyanide. — This test is very simple, 
rapid and accurate. It requires no heat, and caustic 
acids are not employed. For these reasons, I advise 
its application. 

To a test tube half-full of clear urine, add two 
drams of a 5 per cent, solution of potassium ferro- 
cyanide, and mix intimately ; then a few drops of 
acetic acid. If albumin is present, a white-yellow 
haziness or cloud will appear. 

Sugar. — Sugar which occurs pathologically in the 
urine is not of the cane-sugar type, but is of the same 
class as grape sugar. This condition is known as 
glucosuria and glycosuria. Sugar occurs in the urine 



URINE AND ITS EXAMINATION. 211 

in diabetes mellitus, obesity, diseases of the brain, 
especially when affecting the medulla ; in certain affec- 
tions of the liver and pancreas; during the adminis- 
tration of certain drugs, as chloral, alcohol, arsenic and 
chloroform (inhalation), and after the excessive use of 
sugar as a food. 

The tests for sugar in the urine are numerous. 
Those which we will consider are Fehling's, Haines' 
and fermentation tests. 

Fehling's Test. — To apply this test a special solu- 
tion is necessary, which is best preserved by having it 
prepared in two solutions. Solution I, or the copper 
solution, consists of copper sulphate or blue vitriol (34 
parts) and water (1000 parts); and Solution 2, or 
the alkaline solution, consisting of sodium-potassium 
tartrate or Rochelle salts (173 parts), sodium hydrate 
or causic soda (60 parts), and water (1000 parts). 

To prepare Fehling's solution, mix equal parts of 
Solutions 1 and 2. 

The test is applied by filling a test tube half-full 
with the prepared solution and heating (boiling) the 
uppermost part ; then add a few drops of the suspected 
urine to the hot solution, when a red-brown coloration 
and precipitate will occur if the sugar be present. 

Haines' Test. — This test is applied in the same man- 
ner as Fehling's ; the difference being in the solution 
used. The Haines' solution is similar to the Fehling's 
solution, excepting that glycerin is used in place of 
Rochelle salts, and is more stable. 

Fermentation. — This test is accurate, but more com- 
plicated than the above, and depends on the fermenta- 
tion of the sugar by yeast. 



212 FEVER NURSING. 

Bile is present in the urine when the natural flow 
of bile is obstructed. The urine is of a golden-brown 
color. 

Gmeliris Test. — Into a test tube two drams of nitric 
acid is placed, and about the same quantity of the urine 
is allowed to gently flow on the surface of the acid. 
If bile is present, a series of colored rings, green, blue, 
brown or yellow, will form at the junction of the two 
liquids. 

Pus is found in the urine in purulent inflammation 
of the kidneys, bladder or urethra. 

Its presence is detected by the addition of caustic 
potash ( potassium hydrate ) and boiling the mixture, 
when a tenacious, ropy mass results. This is Donne's 
test. 



CHAPTER XXVI. 

SIGNS OF THE ONSET OF THE TOXIC 
EFFECTS OF DRUGS. 

It is important that the nurse should be familiar with 
the action of certain drugs, so that in the absence of 
the physician if the full physiologic action of the drug 
be taking effect, further harm may be avoided. 

This list includes the more common and important 
drugs. 

Drug. Sign. 

Acetanilid. Cyanosis, sweating, feeble pulse and 

cold skin. 
Aconite. Tingling sensation of the skin, vom- 

iting, weak pulse. 
Arsenic. Puffiness of the lower eyelids, indiges- 

tion, diarrhea, headache. 
Bromids. Acneal eruption on the face and back, 

malaise, and indigestion. 
Belladonna. Dryness of the nose, mouth and throat ; 
dilatation of the pupils; skin be- 
comes red and dry ; dizziness ; gid- 
diness. 
Carbolic Acid.Headache, vomiting, diarrhea, darkly 

colored urine. 
Colchicum. Nausea, vomiting, purging, and weak 
pulse. 



213 



214 



FEVER NURSING. 



Digitalis. Slow pulse, which becomes rapid and 

irregular if the patient sit up ; pale- 
ness of the face; vomiting of mu- 
cus and bile. 

Ergot. Numbness, tingling sensation, feeling 

of cold, vomiting, purging, paleness 
of the surface. 

Iodids. Running of the eyes and nose, injec- 

tion of the conjunctivae, acneal erup- 
tion, diarrhea, and salivation. 

Mercury. Salivation, diarrhea, metallic taste in 
the mouth, sore gums, fetor of the 
breath, colicy pains, and paralyses. 

Nitroglycerin.Flushing of the face, throbbing head- 
ache, fullness of the head. 

Opium. Constipation, sweating, dryness of the 

mouth, contracted pupils. 

Ouinin Fullness of the head, buzzing and ring- 

ing in the ears, deafness, dizziness, 
and headache. 

Salicylates. See Quinin. 

Strychnin. Twitchings of the body, restlessness, 
tingling sensation, and convulsions 
later. 

Turpentine. Violet-like odor to the urine, red erup- 
. tion, painful urination, and bloody 
urine. 



CHAPTER XXVII. 
POISONS AND THEIR ANTIDOTES. 

Poisoning may be classified as acute and chronic. 
The acute form may result from an overdose of a drug 
taken by mistake, or for suicidal purpose. The 
chronic form results from the continuous administra- 
tion of a drug, or from being constantly in contact with 
certain poisons, as a painter or type-worker becomes 
lead-poisoned, or workers in match factories suffer 
from phosphorus poisoning. 

Treatment of Acute Poisoning. — The indications 
are : To remove the poison from the body as soon as 
possible ; to render inert the poison which cannot be 
removed ; to counteract the toxic action of the poison, 
and to support the patient with stimulants, if necessary. 

Removal of the Poison. — This is brought about by 
emesis and catharsis. If there is reason to believe 
that some of the poison still remains in the stomach, 
emetics should be resorted to. Among the common 
and most used emetics are salt water, made by dis- 
solving a teaspoonful of salt in a cup of lukewarm 
water; ipecac (30 grains of the powder or 30 m. of 
the fluid extract) ; apomorphine, given hypodermic- 
ally in doses of one-fifteenth to one-tenth of a grain. 

Cathartics may be used to remove the toxic material 
that has gained entrance to the intestines. 

215 



2l6 FEVER NURSING. 

To Render the Poison Inert. — This is made pos- 
sible by the use of antidotes which act either mechan- 
ically or chemically. The mechanical antidotes de- 
crease the toxic effects of poisons by preventing or 
lessening their absorption, and are principally fixed 
oils, as cottonseed, olive or linseed oils ; also, milk, 
starch paste and gummy or mucilaginous drinks, as 
flaxseed and slippery elm teas. The chemical antidotes 
render the poisons inert by neutralizing them or chang- 
ing them into less toxic or non-poisonous substances. 
The chemical antidotes to acids are limewater, chalk, 
magnesia, bicarbonates, milk, white of egg, etc. The 
chemical antidotes of alkalies are diluted acids, lemon 
juice, vinegar, acid lemonade, white of egg, milk, etc. 
The chemical antidotes to alkaloids are tannic acid, po- 
tassium permanganate, strong tea. 

To Counteract Poisons. — This is brought about by 
giving drugs whose actions are diametrically opposed 
to the actions of the poison taken. Here are given a 
list of drugs, with their antagonists : 

Aconite, aconitin (digitalis, atropin). 

Atropin, belladonna (morphin, eserin, policarpin, 
aconitin). 

Belladonna. See atropin. 

Chloral (strychnin, amyl nitrate). 

Cocain (strychnin, alcohol, nitroglycerin). 

Digitalis (nitroglycerin, aconite, senega). 

Hyoscin (pilocarpin, morphin). 

Hyosyamus. See atropin. 

Morphin (atropin, strychnin, caffein). 

Nitroglycerin (ergot, atropin, suprarenal extract). 

l Nux vomica. See strvchnin. 



POISONS AND THEIR ANTIDOTES. 



217 



Opium. See morphin. 

Physostigmin, or eserin (atropin, strychnin). 

Pilocarpin (atropin, alcohol). 

Strychnin (chloral, bromids, morphin, eserin). 

Veratrum viride (atropin, digitalis). 

Stimulation is necessary in all cases of severe 
poisoning. The most used are: Ammonia (aromatic 
spirits), ether, alcohol (brandy, whiskey), digitalis, 
strychnin, atropin and amyl nitrite. 



SPECIAL ANTIDOTES, 
POISON. 

Acetanilid, antipyrin, phe- 
nacetin, migraine tab 
lets, and headache cures 

Acid, Carbolic, salol, creo- 
sote, etc. 



Acid, Hydrocyanic. 
Amyl Nitrite, nitroglycer- 
in and the nitrites. 

Arsenic, Fowler's, Pier- 
son's and Donovan's so- 
lutions, Paris Green, 
etc. 

Belladonna, atropin, and 
hyoscyamus. 

Bromids. 



ANTIDOTE. 

Plenty of air, hot applica- 
tions and stimulation. 



Whiskey by mouth, soluble 
sulphates, as Epsom or 
Glauber salts, white of 
egg, milk, and stimu- 
lants. 

Oxygen and stimulants. 

Fresh air, tincture of digi- 
talis and other stimu- 
lants. 

Dialyzed iron, iron hy- 
drate (mix dilute am- 
monia water with a so- 
lution of iron sulphate) . 

Morphin and stimulants. 

Stimulants. 



2l8 



FEVER NURSING. 



Castor Oil Beans. 

Chloral. 

Cocain. 

Digitalis, squill, strophan- 
tus, and convallaria. 
Lead compounds. 



Mercury. 

Opium, morphin, and co- 
\ dein. 



Phosphorus, matches, rat 

poison. 
Poison-ivy. 



Strychnin. 

Sulfonal, trional, etc. 

Veratrum. 



Opium for the colic and 
stimulants. 

Strong coffee and strych- 
nin. 

Stimulants and oxygen. 

Saline cathartics and stim- 
ulants. 

Sulphuric acid lemonade, 
milk, white of egg, sa- 
line cathartics, hot fo- 
mentations, opium for 
the cramps, and the io- 
dids. 

See Lead. 

Potassium permanganate 
by mouth and hypo- 
dermically, tannic acid, 
coffee, atropin, flagella- 
tion. 

Oil of turpentine, Epsom 
salts, and stimulants. 

Apply fluid extract of 
grindelia, saleratus, or 
lead acetate solution. 

Chloral, bromids, and 
stimulants. 

Sodium bicarbonate, strong 
coffee, and stimulants. 

Stimulants. 



CHAPTER XXVIII. 
ENEMATA AND TOPICAL APPLICATIONS. 

ENEMATA. 

The uses of enemata are : To clean out the lower 
bowel ; to supply nourishment ; to introduce water 
into the system ; for medication, both general and local. 
To Clean Out the Lower Bowel. — Soap Suds. 
Agitate one ounce of soft soap with one and one-half 
pints of warm water. 

Glycerin. Equal parts of glycerin and water; about 
one ounce of each. 

Purgative. To one pint of soap suds (see above) 
add one ounce of Epsom salts, one dram to one-half 
ounce of turpentine, and one ounce of glycerin. 

Oxgall. To the purgative enema add ten grains of 
powdered inspissated oxgall. 

Oil. One pint of warm cotton-seed oil. 
For Nourishment. 

Peptonized milk, 3 ounces. 

Peptonized beef-tea, 1 ounce. 

Whiskey or brandy, y 2 ounce. 

Egg, One. 

To Introduce Water. — Useful in septicemia, shock 
and hemorrhage. Use normal saline solution. 

219 



220 FEVER NURSING 

For Medication. — Uses: As a local medication; 
because of the ill taste of certain medicines ; inability 
to take medicines by mouth, as in coma, because of 
nausea and vomiting, or disease of the stomach. 

Medicines most commonly given per rectum are 
chloral, bromids, digitalis, and whiskey. 

Asafetida. — This is given for the purpose of reliev- 
ing distention of the abdomen and colic. It is espe- 
cially useful in the colic of infants. Take four ounces 
of the emulsion of asafetida (made by agitating one 
dram of powdered asafetida with four ounces of 
water) and four ounces of warm water. 

Turpentine. — Also used to relieve tympanites. 
Turpentine, I dram to I ounce. 
Olive oil, y 2 to 2 ounces. 
Warm water to 4 ounces. 

Quassia. — Is used for pinworms in the rectum. To 
one dram of quassia add one-half pint of cold water, 
and allow to stand for three hours ; then strain and use 
all for one injection. 

Starch and Laudanum. — To some powdered starch 
add a small quantity of cold water and stir thoroughly. 
Then add sufficient boiling water to make a thin, clear, 
mucilaginous liquid. To one ounce of this solution 
add one to fifteen minims of laudanum. 

TOPICAL APPLICATIONS. 

Poultices. — The uses of poultices are chiefly two- 
fold : to apply heat and moisture. They relax the 
vessels and relieve tension and pain. The secret of 
making poultices consists in stirring the material into 
the boiling water and spreading it on hot cloths in a 



ENEMATA AND TOPICAL APPLICATIONS. 221 

thick layer. Let the poultice remain on the surface 
of the body until cool and then replace with another. 

Flaxseed. — Onto boiling water sprinkle ground flax- 
seed meal and stir vigorously, adding more meal until 
the mixture assumes the consistency of porridge. Then 
spread on the cloth. 

Mustard. — Into a thin flaxseed meal poultice stir 
ground mustard in the proportion of from one to two, 
to twelve, according to the age of the patient and the 
desired action. 

Bran. — Make a small bran cushion or pillow and 
pour over it boiling water; then wring it dry in a 
towel. 

Bread. — Take thick slices of bread and pour on boil- 
ing water for five minutes ; then break the bread and 
apply as a poultice. 

Another method is to let the bread simmer for five 
minutes in the water, when the bread becomes pulpy. 
Apply. 

Charcoal. — This form of poultice is very useful for 
removing the odor of putrid ulcers. To the bread or 
flaxseed poultice add powdered charcoal. 

Stupes. — Turpentine. Pour on a piece of flannel 
some very hot water; then wring the flannel dry in 
a towel and sprinkle with twenty to fifty drops of tur- 
pentine. 

Another method is to add to one quart of boiling 
water one teaspoonful of turpentine; into this im- 
merse the flannel and wring dry in a towel. 

Chloroform and Turpentine. — Same as the turpen- 
tine stupe, adding five to fifteen drops of chloroform. 



CHAPTER XXIX. 

ANTISEPTICS AND DISINFECTION. 

Bichlorid of mercury is used in watery solutions 
of from one to five hundred, to one to one thousand. 
The most common dilution is the latter. This solution 
is used for the disinfection of the hands and tissues. 
For irrigating or for use in the abdomen weaker solu- 
tions, as from one to two thousand to one to ten thou- 
sand. Bichlorid is liable to coagulate the albumen of 
the tissues and thus prevent deep disinfection. 

Bichlorid of mercury should not be used to sterilize 
metallic instruments as it corrodes them and destroys 
the edges of sharpened instruments. 

Toxic effects may result from the absorption of mer- 
cury through the skin. The signs are salivation, sore 
gums, foul breath, abdominal colic, diarrhea, etc. 

In preparing solutions of the bichlorid of mercury 
it is best to add common salt, ammonium chlorid or 
citric acid, as these prevent the decomposition of the 
bichlorid. 

Carbolic acid is next in importance. It is used 
in solutions ranging from one to ten to one to one hun- 
dred. A one to twenty solution is most generally used 

222 



ANTISEPTICS AND DISINFECTION. 223 

for sterilizing instruments. A one to one hundred so- 
lution is used for packs and irrigation. 

Signs of carbolic acid poisoning are headache, diz- 
ziness, vomiting, painful urination, dark colored urine, 
and diarrhea. Local gangrene has resulted from the 
application of weak solutions of carbolic acid. 

Potassium permanganate is used for douches in 
a solution of one to one thousand. 

Iodoform is used especially in tubercular disease 
as iodoform gauze, emulsion, or powder. 

Formaldehyd in two per cent solutions for steril- 
izing the hands or instruments. 

Hydrogen peroxid used in the strength dispensed 
or diluted, is especially useful in cleaning pus cavities. 
Creolin is used in two and four per cent solutions 
for douches and irrigation. 

Boric acid as a weak antiseptic for the eyes, nose 
and bladder. 

Lysol, to be used as creolin. 

Aristol has the same use as iodoform and is nearly 
free from odor. 

Chlorinated lime is useful for disinfecting the ex- 
creta of the body. 

TABLE OF SOLUTIONS. 

To one pint of water or the solvent used, add the 
following quantities of the chemical or drug. 

For a 1 to 5000 or a 1-50 per cent solution use 1^2 
grains. 

For a 1 to 2000 or a 1-20 per cent solution use 
Z 2 /z grains. 

For a 1 to 1000 or a 1-10 per cent solution use jYs 
grains. 



224 FEVER NURSING. 

For a I to ioo or a I per cent solution use 73 grains. 

For a 1 to 20 or a 5 per cent solution use 365 grains. 

For a 1 to 10 or a 10 per cent solution use 730 grains. 

Note. — To one ounce of water add one dram of 
chemical, and one dram of this solution when added to 
one pint of water will give approximately a one to one 
thousand solution. 

The New York State Department of Health issues 
a very instructive circular on "Disinfection and Dis- 
infectants," which is here given in part : 

Disinfection and Disinfectants. 

For the prevention of the spread of contagious and 
most infectious diseases nothing is more important 
after the diagnosis of the case than the proper care 
of the various discharges or excretions from the eyes, 
nose, mouth, skin, and of the excreta of the bowels 
and bladder of the sick. 

As the diagnosis of the disease cannot always be 
made as soon as some of these discharges or excreta 
become dangerous to others, every person suspected of 
having either consumption, typhoid fever, diphtheria, 
smallpox, measles, whooping-cough or cerebrospinal 
meningitis should be treated as if the diagnosis had 
been made positively. 

SICK-ROOM AND ITS CARE. 

Above all else, cleanliness must be observed. All 
other precautions are likely to fail in its absence. 

1. The patient should be placed in an isolated room, 
which should have in it as little furniture as possible. 



ANTISEPTICS AND DISINFECTION. 225 

Iron bedsteads and plain wooden furniture are the 
most suitable. Carpets, draperies and curtains should 
be removed. A sheet kept moistened with carbolic 
solution (1-40) or bichlorid solution (1-1000) should 
be hung from the top of the door. The floor, wood- 
work and furniture should be wiped daily with a cloth 
moistened preferably with carbolic solution (1-40). 
The floor should not be swept while dry. It should be 
sprinkled with sawdust, bran or other granular ma- 
terial thoroughly moistened with carbolic solution 
(1-20), and then carefully swept so that no dust may 
arise. Flies should be absolutely excluded from the 
sick-room. For this purpose mosquito netting should 
be tacked on the window frames outside so that each 
entire window is covered, and a screen door should be 
put up at the entrance to the room if flies are not ex- 
cluded from the entire house. The sheet moistened 
with carbolic solution may be hung on this door. 
Household pets must be excluded. 

2. Plates, cups, glasses, knives, forks, spoons and 
all other utensils used by the patient should be kept 
for his use alone, and under no circumstances should 
they be removed or mixed with similar utensils used 
by others. They should be placed in carbolic solution 
(1-20) immediately after use and remain there for an 
hour or longer, after which they should be washed in 
hot, strong soapsuds and rinsed with boiling water. 

3. The patient's clothing, the sheets, pillow cases, 
towels, napkins and other clothing which have been in 
contact with the patient should be placed after use into 
carbolic solution (1-20) or bichlorid solution (1-500) 
for at least one hour, after which they should be thor- 

15 



226 FEVER NURSING. 

ouglily washed. The outside clothing worn by the 
attendant should be treated in the same manner. 

4. Any articles or surfaces soiled by discharges 
should be immediately washed with carbolic solution 
(1-20). 

5. The discharges from the nose, mouth, ears or 
eyes should be received on cloths or paper napkins, and 
these, together with remnants of food, should be 
burned at once by the attendant. If handkerchiefs are 
used they should be immersed in carbolic solution 
(1-20) before the discharges dry. 

6. In cases of typhoid fever, scarlet fever and dys- 
entery the discharges from the bowels and the urine 
should be received into bedpans or other vessels con- 
taining small amounts of either carbolic solution 
(1-20), bichlorid solution (1-500) or chlorid of lime 
solution, and a quantity of the same disinfectant equal 
in volume to that of the discharges should be added, 
and the whole protected from flies and allowed to 
stand for one hour and then dumped into the water- 
closet. If only a privy is available, fresh chlorid of 
lime should be added, followed by earth or ashes ; or 
the disinfected stools may be buried in a trench, which 
must be remote from and, if possible, down hill from 
the well or nearest watercourse. The trench should 
be four feet deep and two wide, and each deposit 
should at once be well covered with quicklime and 
earth well beaten down, the trench being covered in 
with earth when half -filled in this manner. Or the 
discharges may be mixed with sawdust and kerosene 
and placed in a watertight kerosene barrel, and after 
recovery or death add more kerosene and burn the 
entire barrel and contents. 



ANTISEPTICS AND DISINFECTANTS. 227 

7. The body of the patient should be washed daily 
with warm water, or as directed by the physician, and 
the water that has been used in such baths should have 
added to it an equal quantity of chlorid of lime solu- 
tion or carbolic acid solution (1-20), and allowed to 
stand for one hour, when it can be emptied down the 
water-closet or into the privy. 

8. After making applications to the throat, nose, 
ears, eyes or after handling the patient in any way, 
before eating, or leaving the sick-room, the hands of 
the attendant should be immersed in carbolic solution 
(1-40) or bichlorid solution (1-1000) and then thor- 
oughly rubbed in hot soapsuds. 

Upon notice from the health officer or physician that 
the sick-room is ready for disinfection, everything 
which has been used by the patient or attendant during 
the illness should be allowed to remain in the room 
for disinfection. 

10. If the disease should terminate fatally, the body 
should be wrapped in a sheet saturated with corrosive 
sublimate solution (1-500), and placed in a tight coffin, 
which should not be opened afterward, and burial 
should take place within twenty-four hours, if possible. 

DISINFECTION OF ROOMS. 

Preparation of Room. — 1. Carefully close all win- 
dozvs and doors, except one door for exit. Paste 
paper over stovepipe hole, and over all window, tran- 
som or door cracks. In a word, seal the room tightly 
from the inside. 

2. Open closet doors, drawers, trunks, boxes, etc 



2 28 FEVER NURSING. 

Suspend clothing and bedclothes upon lines stretched 
across the room, or spread out on chairs or clothes- 
horses. Books must be opened and the leaves spread ; 
in short, the room and its contents must be so disposed 
as to secure free access of gas to all parts and to all 
objects. 

3. The next point is to make the air in the room 
damp; this is absolutely necessary for disinfection, 
either by sulphur or formaldehyd. Dampness may 
be produced ( a ) by boiling water on a gas or gasoline 
stove; (b) by pouring boiling hot water from a tea- 
kettle into a tub ; ( c ) by pouring cold water onto hot 
bricks or stone, or by dropping hot bricks or stones 
into vessels containing- cold water. Under no circum- 
stances is efficient disinfection possible without in some 
way making the air of the room quite damp. The tem- 
perature should also be 6o° F. or over. 

4. Measure the room, and get the length, breadth 
and height in feet. Multiply the figures together, dis- 
regarding the fractions. This will give the cubical 
contents of the room in feet. Divide by 1000, and we 
know the number of thousand cubic feet in the room. 
Example: Suppose a room to be 24 feet long. iy/ 2 
feet wide and 12^4 feet high. Disregarding fractions, 
the cubical contents of the room is 24 X 13 X 12 
(=3.744) cubic feet: and the number of thousand 
cubic feet is 3.7, or, approximately. 3^4. 

Sulphur Disinfection. — For each 1000 cubic feet, 
weigh out four pounds of powdered or roll sulphur 
and place it in an iron kettle or dishpan, or take 
four tins of pressed sulphur, or four one-pound sul- 
phur candles, setting the last in saucers. For the room 



ANTISEPTICS AND DISINFECTANTS 229 

mentioned in the above example, fifteen pounds of sul- 
phur would be used. Stand the dishpan, tins or 
saucers in a tub containing two inches or more of 
water, and place the same on a table ; do not put it on 
the floor. The water is put in the tub to guard against 
fire ; it must not come in contact with the sulphur, and 
bricks can be placed under saucers to prevent this. 
Dampen the powdered or roll sulphur in a spot not 
larger than a silver dollar with alcohol or coal oil, and 
apply a match to the same, or to the wicks of the 
candles. Without delay, retire from the room, closing 
the door, and paste paper on the outside of the keyhole 
and cracks. The room must remain closed for at least 
ten or, better, twenty-four hours. When the time is 
up, the windows should be opened, if possible from the 
outside, and the room thoroughly aired. The room 
and contents may now be considered free from infec- 
tion, if the work has been properly carried out, but any 
mattresses, rugs, carpets, blankets and other unwash- 
able materials must be hung in the open air and sun- 
shine for several days. Sheets, pillow cases, bed- 
clothes and the patient's and attendant's clothing should 
be thoroughly washed, using boiling water. The floor, 
woodwork, bureau, bedstead, table and chairs must be 
washed with soap and water. 

Disinfection with Formaldehyd Gas. — Prepare the 
room as described above. Take one pint of 40-per- 
cent, solution of formaldehyd and eight ounces of 
crystalline permanganate of potassium for each 1000 
cubic feet. The room mentioned above would need 
three and three-quarters pints of formaldehyd and 
thirty ounces of permanganate. Place the perman- 



230 FEVER NURSING. 

ganate in a dishpan, stone crock or other vessel large 
enough to hold as many gallons as there are pints of 
formaldehyd. This is to make sure the liquid will not 
boil over. Set the pan or crock inside of a slightly 
larger wooden pail, tub or crock, to retain the heat 
generated in the mixture ; or wrap the pan or crock in 
two layers of asbestos paper or blankets. Now the 
vessel containing the permanganate is placed in the 
center of the room and the formaldehyd is poured onto 
it from a pitcher. The operator must immediately 
retire from the room and close the door. Keep the 
room closed for six to ten hours, then open all win- 
dows and doors and air thoroughly. Finally, clean all 
the contents of the room, as directed after sulphur 
disinfection. 

Formaldehyd gas does not injure fabrics nor metals 
as does sulphur. It must not be breathed, and it would 
be well not to have the strong liquid formaldehyd come 
into contact with the skin. Formaldehyd disinfection 
can be accomplished in other ways very satisfactory, 
but such methods should be used only by those having 
considerable training and experience with methods of 
room disinfection. Do not use any methods unless the 
same have been personally recommended to you by a 
physician or a person expert in the details of room 
disinfection. Do not rely upon patented solutions and 
methods. 

Disinfection of Clothing. — If one's clothing becomes 
infected by visiting cases of measles, scarlet fever, 
diphtheria, etc., or in any way, it may be disinfected 
with formaldehyd as follows : Place the clothing in a 
trunk, washboiler or covered box, one piece at a time, 



ANTISEPTICS AND DISINFECTANTS. 23 1 

covering each piece with a towel, pillowslip, sheet or 
piece of cloth, and sprinkle or spray on each cover, as 
it is laid on, two tablespoonsful of 40 per cent, for- 
maldehyd. When the trunk or boiler is full, put on 
the cover and let stand for six hours, then open, and 
air the clothing. Each piece of clothing must be 
covered to protect it from being spotted by the 
formaldehyd. 



CHAPTER XXX. 

ABBREVIATIONS, WEIGHTS AND 
MEASURES. 

ABBREVIATIONS. 

Aa. — Of each. 

A. C. — Before Meals. 
Aq. — Water. 

Aq. Bui. — Boiling Water. 
Aq. Dest.— Distilled Water. 
Aq. Ferv.— Hot Water. 
Aq. Font. — Spring Water. 
Bene.— Well. 

B. I. D. — Twice a Day. 
C— With. 

Cochl. — Spoonful. 
Cras. — To-morrow. 
D.— Dose. 
Ft.— Make. 
Gr. — Grain. 
Gm.— Gram. 
Gtt.— Drop. 
M. — Minim. 
O.— Pint. 

P. C— After Meals. 
Q. 4. H. — Every four hours. 
232 



ABBREVIATIONS, WEIGHTS AND MEASURES. 233 

0. S. — Sufficient Quantity. 
Sine. — Without. 

Stat. — Immediately. 

T. I. D. — Three Times a Day. 

IV. I. D. — Four Times a Day, 

WEIGHTS AND MEASURES. 

Apothecary's Weight. 

60 Minims, I Dram. 
8 Drams, i Ounce. 
16 Ounces, I Pint. 
Troy Weight. 

20 Grains, I Scruple. 
3 Scruples, i Dram. 
8 Drams, I Ounce. 
Metric Values. 

0.0081 Gram, 1-8 Grains. 
0.056 Gram, 7-8 Grains. 
0.1 Gram, 1.54 Grains. 
0.5 Gram, 7.71 Grains. 
0.9 Gram, 13.89 Grains. 

1. Gram, 15.43 Grains. 
I. CC, 16.23 Minims. 



Equivalents. 



1 Grain, 0.065 Grams. 

2 Grains, 0.13 Grams. 
5 Grains," 0.324 Grams. 

15 Grains, 0.972 Grams. 
480 Grains, 31.103 Grams. 

1 Minim, 0.0616 CC. 

2 Minims, 0.1232 CC. 
5 Minims, 0.3080 CC. 



2 34 



FEVER NURSING. 



Equivalents. 




60 Minims, 3.7 CC. 


480 Minims, 29.6 CC. 


1 Pint, 0.473 Liters. 


I Quart, 0.946 Liters. 


1 Gallon, 3.784 Liters. 


1 Liter, 33.8 Ounces. 


Domestic Measures. 


1 Teaspoonful, 1 Dram or 4 CC. 


1 Dessert spoon, 2 Drams or 8 CC. 


1 Table spoon, 4 Drams or 16 CC. 


1 Wine glass, 2 Ounces. 


1 Tea cup, 5 Ounces. 


1 Tumbler, 11 Ounces. 


Th ermom etric Equivalents. 


212. Fahrenheit — 100. ° Centigrade. 


120. ° 


" - 49-° 


100. ° 


' — 37-77° 


98.6 


1 - 37-° 


80. ° 


1 — 27. ° 


60. ° 


' — 16. 


5o.° 


" — io.° 


32. 


1 — o.° 


o.° " - 17.78 — 


To reduce Cent 


igrade to Fahrenheit, multiply by 



nine and divide by five, and add thirty-two. 

To reduce Fahrenheit to Centigrade, subtract thirty- 
two, multiply by five, and divide by nine. 



CHAPTER XXXI. 

MISCELLANEOUS NOTES. 

The Stools. — Green. In gastro-intestinal disease of 
children, excessive flow of bile, after taking calomel. 

Black. — From altered blood, after certain foods as 
spinach, huckleberries. Certain medicines as iron, bis- 
muth, tannin, and charcoal. 

Yellow. — In typhoid fever, certain drugs as senna, 
santonin, and rhubarb. 

Red. — After administering logwood. 

Watery. — In profound diarrheas, cholera, poisoning 
by mercury, arsenic, and antimony. 

Mucous. — In inflammation of the colon, dysentery, 
after prolonged constipation. 

Fatty. — In faulty pancreatic digestion ; in the ab- 
sence of bile, as in obliterative jaundice; after the in- 
gestion of an excessive amount of fat. 

Purulent. — From ruptured abscesses of the intestinal 
tract, fistula in ano, dysentery, suppurative enteritis. 

Bloody. — In typhoid fever, ulcers of the intestines, 
dysentery, intussusception, intense anemia, scurvy, 
acute enteritis. 

Expectoration. —Mucous. It is glairy and clear, 
like the white of an Qgg y and occurs in acute bronchitis, 
asthma, and edema of the lungs. 

235 



236 FEVER NURSING. 

Purulent. — In ruptured empyema, abscess of the 
lung, ruptured abscesses of the mediastinum and liver. 

Mucopurulent. — In bronchitis, lobar pneumonia, tu- 
berculosis. 

Serous. — In edema of the lungs. 

Bloody. — In beginning pneumonia, tuberculosis, can- 
cer of the lung, congestion of the lung following heart 
disease. 

Pulse. — Rapid. In fevers, tuberculosis, infections, 
exophthalmic goiter, shock, rheumatoid arthritis, loco- 
motor ataxia, valvular heart disease, certain drugs. 

Slow. — In disease of the heart muscle, as fatty de- 
generation : in jaundice ; brain tumor ; basal meningi- 
tis ; during the convalescence of pneumonia and ty- 
phoid fever; after drugs, as digitalis, aconite, opium, 
and strophanthus . 

Temperature and Pulse Ratio. 

Pulse of ~2 corresponds to 98. 6° F. 

Pulse of 80-90 corresponds to ioo c F. 

Pulse of 1 00-115 corresponds to 102° F. 

Pulse of 120-130 corresponds to 104 F. 



INDEX. 



Abbreviations, 232 
Acetanilid, antidotes for, 217 
Acid, carbolic, antidotes for, 217 

hydrocyanic, antidote for, 217 

uric, in urine, 208 
Acids, antidotes for, 216 
Air, composition of, 21 

fresh, necessity of, 22 

of sick room, 21-25 
Albumin milk, recipe for, 37 

in urine, 209 
tests for, 209 

water, recipe for, 36 
Alkalies, antidotes for, 216 
Alkaloids, antidotes for, 216 
Amyl nitrite, antidotes for, 217 
Amyotrophic spinal paralysis, 138 
Antidotes for acids, 216 

for alkalies, 216 

for alkaloids, 216 

for poisons, 215, 217 

special, 217 
Antiseptic solutions, preparation 

of, 223 
Antiseptics, 222 
Antitoxin, 193 

diphtheria, 164 
ill effects of, 164 
method of administering, 165 

production of, 195 



! Antitoxin, varieties of, 196 
Arrowroot water, recipe for, 36 
Arsenic, antidotes for, 217 
Arthritis as a complication, 63 
Asafetida, enema, 220 
Atrophic spinal paralysis, acute 
138 

Bacilli, 201 

Bacillus of diphtheria, 157 

of influenza, 202 

of tuberculosis, 203 

of typhoid fever, 72, 201 

paratyphosus, 89 
Bacteria, 199 

classification of, 199 

definition of, 199 

growth of, 200 

media for, 200 

nutrition of, 200 
Bacterial vaccines, 197 
Barley-water, recipe for, 35 
Bathing, notes on, 47 
Baths, bed, 44 

foot, 46 

forms of, 42 

in typhoid fever, 83 

sheet, 46 

sitz, 47 

sponge, 45 

237 



23» 



INDEX. 



Baths, temperature of, 47 
therapeutic indications, 42 
tub, 42 
Bed baths, 44 

preparation of, in sick room, 26 
sores as a complication, 64 

causes of, 48 

in typhoid fever, 85 

prevention of, 48 

treatment of, 49 
Beef tea, peptonized, 38 
Belladonna, antidote for, 217 
Bile in urine, 212 

tests for, 212 
Biliuria, 206 

Boiled custard, recipe for, 38 
Bran poultice, 221 
Bread poultice, 221 
Bromids, antidote for, 217 
Bronchitis as a complication, 64 

Carbolic acid, antidotes for, 217 

Carphologia, 65 

Castor oil beans, antidote for, 218 

Catheterization, 59 

Centigrade, Fahrenheit equiva- 
lents for, 234 

Cerebrospinal meningitis, 134. 
See also Meningitis. 

Charcoal poultice, 221 

Chicken-pox, diagnosis of, from 
smallpox, 97 

Children, fever in, 17 

Chloral, antidote for, 218 

Chlorids in urine, 209 

Chloroform and turpentine 
stupes, 221 

Choluria, 206 

Chyluria, 205 



Clam milk, recipe for, 38 
Clothing, disinfection of, 229 
Cocain, antidote for, 218 
Coil, cold water, 41 
Cold water coil, 41 
Coma vigil, 65 
Complications of fevers, 62 
Constipation, causes of, 49 

treatment of, 49, 87 
Convulsions as a complication, 

65 

treatment of, 49 
Crisis in fevers, 18 

of pneumonia, 150 
Custard, boiled, recipe for, 38 

Degrees of temperature, 14 
Delirium as a complication, 65 

forms of, 50 

in typhoid fever, 78, 87 

treatment of, 50. 87 
Detection of temperature, 15 
Diarrhea as a complication, 66 

treatment of, 50, 86, 220 
Diet in scarlet fever, 109 

in smallpox, 101 

in typhoid fever, 82 

of sick, 29, 39 
Digitalis, antidote for, 218 
Diphtheria, 157 

antitoxin in, 161 -164 

bacillus of, 157, 202 

care and management of, 161 

complications of, 63, 159 

definition of, 157 

etiology of, 157 

intubation in, 166 

laryngeal form of, 159 

prognosis of, 160 



INDEX. 



239 



Diphtheria, quarantine in, 167 

symptoms of, 158 

temperature in, 158 

transmission of, 160 

treatment of, 163, 164 
Discharges, care of, 226 
Disinfection, 222 

methods of, 112 

of clothing, 229 

of rooms, 227 

sulphur, 228 

with formaldehyd gas, 112, 229 
Donne's test for pus in urine, 

212 
Draughts in sick room, danger, 22 
Drugs causing temperature fall, 14 
temperature rise, 14 

toxic action of, 213 

Edema of lungs as a complication, 

66 
Egg-nog, recipe for, 38 
Eggs as food, 35 
Emesis. See Vomiting. 
Emetics in poisoning, 215 
Endocarditis as a complication, 

66 
Enemata, 219 

asafetida, 220 

glycerin, 219 

nutritive, 219 

oil, 219 

oxgall, 219 

purgative, 219 

quassia, 220 

saline, 219 

starch and laudanum, 220 

turpentine, 220 

uses of, 219 



Enteric fever, 71. See also Ty- 
phoid fever. 
Enteroclysis, 55 

technic of, 56 
Epidemic poliomyelitis, 138 
Epistaxis, treatment of, 52, 87 
Eruption of German measles, 120 

of measles, 115 

of scarlet fever, 104 

of smallpox, 96 

of typhoid fever, 76 
Erysipelas, 182 

care and management of, 183 

complications of, 63, 183 

definition of, 182 

etiology of, 182 

prognosis of, 183 

symptoms of, 182 
Expectoration, significance of, 

235, 236 

Fahrenheit, centigrade equiv- 
alents for, 234 
Farina gruel, recipe for, 39 
Fastigium, the, 17 
Fehling's test for sugar in urine, 

211 
Feeding, frequency of, 30 
Fever, antemortem, 17 
complications of, 62 
continued, 18 
definition of, 13 
detection of, 15 
in children, 17 
in measles ,115. See Measles. 
in pneumonia, 150. See also 

Pneumonia. 
in rheumatism, 169. See also 
Rheumatism. 



2/j-O 



INDEX. 



Fever, detection of, in scarlet 
fever, 105. See also Scarlet 
fever. 
in smallpox, 96. See also 

Smallpox. 
in typhoid fever, 74. See also 
Typhoid fever. 
intermittent, 18 
invasion period of, 17 
phenomena of, 18 
prognosis of, 16 
reduction of, 40 
remittent, 18 
stages of, 17 
treatment of, 18 
types of, 1.8 
Flaxseed poultice, 221 

tea, recipe for, 37 
Flies, exclusion of, from sick- 
room, 225 
Fomentations, 221. See also 

Stupes. 
Food, definition of, 29 
Foodstuff, definition of, 29 
Foot-bath, 46 
Formaldehyd disinfection, 112, 

229 
Furniture of sick room, 25 

Gelatine, recipe for, 39 
German measles, 119 

diagnosis of, 120 

eruption of, 120 

etiology of, 119 

management of, 120 

symptoms of, 119 
Glycerin enema, 219 
Gmelin's test for bile in urine, 
212 



Haines' test for sugar in urine, 

21T 
Headaches, treatment of, 51 
Hematuria, 205 

Hemorrhage from bowel as a 
complication, 66 
occurrence of, 51 
treatment of, 51 

from lungs, treatment of, 52 

from nose, treatment of, 52 
Hydrocyanic acid, antidote, 217 
Hydrotherapy, definition of, 40 

in typhoid fever, 83 

methods of, 40 
Hypodermoclysis, 53 

indications for, 54 

technic of, 54 

Ice-bag, uses of, 40 
Ice-poultice, 41 
Immunity, 193 
Imperial drink, recipe for, 37 
Infantile paralysis, 138 
Influenza, 129 

care and management of, 131 

complications of, 63, 131 

convalescence from, 133 

course of, 130 

definition of, 129 

forms of, 130 

prognosis of, 131 

sequelae of, 131 

symptoms of, 129 

synonyms of, 129 
Insomnia, treatment of, 52 
Intestinal hemorrhage as a com- 
plication, 66 

perforation as complication, 67 
Intubation in diphtheria, 166 



INDEX. 



241 



Junket, recipe for, 37 

Kernig's sign in meningitis, 135 
Kilmer belt, 127 
Koplik's sign in measles, 115 
Kumiss, recipes for, 38 

La grippe, 129. See also In- 
fluenza. 

Laudanum and starch enema, 220 

Lead compounds, antidotes for, 
218 

Lime water, recipe for, 36 

Lumbar puncture in meningitis, 
136 

Lungs, edema of, as a complica- 
tion, 66 

Lysis in fevers, 18 

Malarial fever, 174 

care and management of, 179 

chronic, 178 

etiology of, 174 

mosquito in, 179 

pernicious, 178 

prognosis of, 179 

remittent, 177 

stages of, 174 

symptoms of, 174 

varieties of, 177 
Mania a potu, 65 
Measles, 114 

care and management of, 117 
complications of, 63, 116 
definition of, 114 
desquamation in, 116 
eruption of, 115 
etiology of, 114 
fever in, 115 
16 



Measles, Koplik's sign in, 115 
prognosis of, 117 
quarantine in, 118 
sequelae of, 118 
symptoms of, 114 
Measures and weights, 233 
Meat as food, 35 

juice, recipe for, 37 
Meningitis, cerebrospinal, 134 
care and management of, 

136 
complications of, 63, 135 
convalescence from, 137 
course of, 135 
diagnosis of, 135 
etiology of, 134 
Kernig's sign in, 135 
lumbar puncture in, 136 
prognosis of, 135 
symptoms of, 134 
Mercury, antidotes for, 218 
Micrococci, 200 

varieties of, 200 
Milk, albumin, recipe for, 37 
as food, 30 
clam, recipe for, 38 
composition of, 30 
daily amount of, 31 
in typhoid fever, 80 
modification for infant feeding, 

3i 
objections to, 31 
oyster, recipe for, 37 
Pasteurized, 80 
peptonized, 38 
punch, recipe for, 37 
sterilized, 80 
Mouth, care of, 50, 86 
wash, 51 



242 



INDEX. 



Movements, bowel, 235. See also 

Stools. 
Mumps, 122 

complications of, 63, 123 

etiology of, 122 

management of, 123 

symptoms of, 122 

synonyms of, 122 
Mustard poultice, 221 

Nephritis as a complication, 68 
Nitrite of amyl, antidotes for, 217 
Nosebleed, 52, 87 
Nutritive enema, 219 

Oatmeal water, recipe for, 36 
Oil enema, 219 
Oliguria, 205 

Opium, antidotes for, 218 
Otitis media as a complication, 68 
Oxgall enema, 219 
Oyster milk, recipe for, 37 
Oysters, peptonized, 39 

Packs, sheet, 46 

Pains in back, treatment of, 57 

in joints, treatment of, 57 
Paralysis, acute atrophic spinal, 
138 
amyotrophic spinal, 138 
as a complication, 68 
infantile, 138 
spinal, 138 
Paratyphoid fever, 89 
complications, 92 
diagnosis, 93 
etiology, 89 
historical, 89 
prodromes, 90 



Paratyphoid fever, prognosis, 92 
symptoms, 90 

alimentary, 90 
temperature in, 92 
treatment, 93 
Parotiditis, 122. See also 

Mumps. 
Pasteurized milk, 80 
Peptonized beef-tea, 38 
milk, 38 
oysters, 39 
toast, 39 
Perforation, intestinal, as a com- 
plication, 67 
Pericarditis as a complication, 69 
Peritonitis, treatment of, 58 
Pertussis, 124. See also Whoop- 
ing-cough. 
Phenomena of fevers, 18 
Phlebitis as a complication, 69 
Phosphates in urine, 209 
Phosphorus, antidotes for, 218 
Plants in sick room, removal of, 

26 
Pleurisy as a complication, 69 

treatment of, 58 
Pneumococcus, 148, 201 
Pneumonia as a complication, 69 
lobar, 148 

care and management of, 

152-155 
chill in, 149 

complications of, 63, 151 
cough in, 149 
course of, 152 
crisis in, 150 
definition of, 148 
etiology of, 148 
fever in, 150 



INDEX. 



243 



Pneumonia, lobar, herpes labialis 
in, 150 

pathology of, 148 

pericarditis in, 151 

prognosis of, 152 

sputum in, 149 

symptoms of, 149 

synonyms of, 148 

urine in, 150 

varieties of, 151 
Poison ivy, antidotes for, 218 
Poisoning, acute, treatment of, 

215 
Poisons and antidotes, 215 

method of rendering inert, 216 

to counteract, 216 
removal of, 215 
Poliomyelitis, acute epidemic 
anterior, 138 
anatomical seat of lesion, 

139 
baths in, 147 
bone dystrophies in, 143 
care and management, 

144 
clothing in, 146 
contractures in, 143 
convulsions in, 141 
definition, 138 
diagnosis, 143 
diet in, 145 
electrical reactions in, 

143 
etiology, 138 
gait in, 142 
motor symptoms, 140 
muscle tone in, 142 
muscular atrophy in, 142 
paralysis in, 140 



Poliomyelitis, acute epidemic an- 
terior, reflexes in, 142 
rubbing in, 146 
sensory symptoms, 142 
symptoms, 139 
synonyms, 138 
trophic disorders in, 142 
Polyuria, 205 
Poultices, 200 
bran, 221 
bread, 221 
charcoal, 221 
flaxseed, 221 
ice, 41 

mustard, 221 
uses of, 220 
Preparation of bed in sick room, 

26 
Pulse, rapid, significance of, 236 

slow, significance of, 236 
Purgative enema, 219 
Pus in urine, 212 
tests for, 212 
Pyemia, definition of, 187 
etiology of, 188 
symptoms of, 188 
treatment of, 189 

Quarantine in diphtheria, 167 

in measles, 118 

in scarlet fever, 112 
Quassia enema, 220 
Quietness in sick room, 27 

Rash. See Eruption. 
Retention of urine, 58 
Rheumatism, acute articular, 168 
care and management of, 
170 



244 



INDEX. 



Rheumatism, acute articular, 
complications of, 63, 170 
course of, 170 
etiology of, 168 
fever in, 169 
symptoms of, 169 
temperature in, 169 
Rice-water, recipe for, 36 
Room, sick, 21. See also Sick 

room. 
Rooms, disinfection of, 228 
Rotheln, 119. See also German 
measles. 

Saline enema, 219 

solution, injection of, 53 
indications for, 54 
technic, 54 
Sapremia, 187 
Scarlatina, 103. See also Scarlet 

fever. 
Scarlet fever, 103 
black, 106 

care and management, of 108 
complications of, 62. 105 
desquamation in, 105 
diet in, 109 
disinfection after, 112 
eruption of, 104 
etiology of, 103 
fever in, 105 
quarantine in, 112 
strawberry tongue in, 105 
symptoms of, 104 
Septicemia, 187 
care in, 189 
definition of, 187 
symptoms of, 188 
Sheet-bath, 46 



Shock, treatment of, 61 
Sick room, air of, 21-25 

care of, 224 

draughts in, danger of, 22 

furniture of, 25 

hygiene of, 21-28 

location of, 25 

plants in, removal of, 26 

preparation of bed in, 26 

quietness in, 27 

selection of, 25 

temperature of, 25 

ventilation of, 21 
Sitz bath, 47 
Smallpox, 95 

care and management of, 98 

complications of, 62, 98 

confluent, 97 

definition of, 95 

diagnosis of, from chicken-pox, 

97 

diet in. 101 

eruption of, 96 

etiology of, 95 

fever in, 96 

hemorrhagic, 97 

initial rash of, 95 

isolation in, 100 

pitting in, 101 

prognosis of, 97 

symptoms of, 95 

vaccination in, 98 

varieties of, 97 
Solutions, antiseptic, preparation 

of, 223 
Specific gravity of urine, 207 
Spinal infantile paralysis, 138 

paralysis, acute atrophic, 138 
amyotrophic, 138 



INDEX. 



245 



Sponge bath, 45 

Stages of fever, 17 

Staphylococcus, 200 

Starch and laudanum enema, 220 

Stools, clinical significance of, 235 

color of, 235 
Strawberry tongue, 105 
Streptococcus, 201 
Strychnin, antidotes for, 218 
Stupes, turpentine, 221 

and chloroform, 221 
Sugar in urine, 210 

tests for, 211 
Sulfonal, antidotes for, 218 
Sulphur disinfection, 228 
Sweating, treatment of, 60 

Temperature, degrees of, 14 

detection of, 15 

in typhoid fever, 74 

of baths, 47 

rectal, 16 

variations of, 13 
Thermometer, uses of, 15 
Thermometric equivalents, 234 
Toast, peptonized, 39 

water, recipe for, 36 
Topical applications, 220, 221 
Toxemia, definition of, 187 

etiology of, 188 

symptoms of, 188 
Toxins, elimination of, methods 

of, 191, 192 
Tub bath, 42 
Tuberculin, 203 
Tuberculosis, bacillus of, 203 
Turpentine and chloroform stupes, 
221 

enema, 220 



Turpentine stupes, 221 
Tympanites, treatment of, 60, 77, 

86 
Types of fevers 18 
Typhoid fever, 71 

bacillus of, 72, 201 

baths in, 83 

bed sores in, 85 

care and management of, 79 

carriers of, 73 

causes of, 71 

clothing in, 81 

complications of, 62 

constipation in, 87 

convalescence from, 87 

countenance in, 76 

delirium in, 78, 87 

diagnosis of, 78 

diarrhea in, 77, 86 

diet in, 82 

disinfection of stools in, 74, 
81 

epistaxis in, 87 

eruption of, 76 

etiology of, 71 

fever in, 74, 83 

milk in, 80 

nervous system in, 78 

prognosis of, 79 

respiratory tract in, 77 

sordes in, 78 

spleen in, 76 

stools in, 77 

symptoms of, 74 

synonyms of, 71 

temperature in, 74 

tongue in, 76 

tympanites in, 77, 86 

urine in, 78 



246 



INDEX. 



Typhoid fever, vomiting in, 77, 
86 
water in, 72, 79 
Widal reaction in, 202 

Urates in urine, 208 
Urea in urine, 208 
Uric acid in urine, 208 
Urine, albumin in, 209 

tests for, 209 
amount voided, 204 
bile in, 212 

tests for, 212 
chlorids in, 209 
collection of, 204 
color of, 205 
constituents of, 208 
density of, 207 
examination of, 204 
odor of, 206 
phosphates in, 209 
properties of, 204 
pus in, 212 

tests for, 212 
reaction of, 207 
retention of, 58 
specific gravity of, 207 
sugar in, 210 

tests for, 211 
urates in, 208 
urea in, 208 
uric acid in, 208 

Vaccination, 98 
importance of, 98 



Vaccination, method of, 99 
signs of, 99 

Vaccines, bacterial, 197 

Variola, 95. See also Smallpox. 

Varioloid, 97. See also Small- 
pox. 

Ventilation, methods of, 22 
of sick rooms, 21 
window, 23, 24 

Veratrum, antidote for, 218 

Vomiting, treatment of, 61, 77, 
86 



Water, albumin, 36 

arrowroot, 36 

barley, 35 

bed, 42 

coil, 41 

oatmeal, 36 

rice, 36 

toast, 36 
Weights and measures, 233 
Whey, wine, 37 
Whispering in sick room, 27 
Whooping-cough, 124 

care and management of, 125 

complications of, 63, 125 

etiology of, 124 

sequelae of, 125 

symptoms of, 124 

synonyms of, 124 
Widal reaction in typhoid fever, 

202 
Wine whey, 37 



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Davis' Obstetric and Gynecologic Nursing 5 

DeLee's Obstetrics for Nurses 5 

Dorland's Medical Dictionaries 7, 8 

Fiske's Anatomy and Physiology for Nurses 4 

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McKenzie, B.A., M.D., Professor of Physical Educa- 
tion, and Director of the Department, University of 
Pennsylvania. Octavo of 406 pages, with 346 illustra- 
tions. Cloth, $3.50 net. 



Manhattan Hospital Eye, Ear, Nose, 
and Throat Nursing 

"* " J S ILLUSTRATED 

This is a practical book, prepared by surgeons who, from their 
experience in the operating amphitheatre and at the bedside 
have realized the shortcomings of present nursing books in 
regard to eye, ear, nose, and throat nursing. 

^"^oPS^^t^ffiE-J-pNo- and Throat. By the 

J. Edward G.les! A. D Sureeon fn" vU'n"' ?" d Thro ? t Hos P ita| : 
DUEL, M. D., (chairman) W^"- y L? De ^ artment; ARTHUR B. 
SAUTH.M.D./Sur/eonfnfhfoaTr^n "? Ea [ De P artment; Harmon 
Shannon, M E > a^uV^q at Department Assisted by John R. 

* Cloth, $i. 5 o net. 

Friedenwald and Ruhrah's Dietetics 
for Nurses 

_ . NEW (2d) EDITION 

This work has been prepared to meet the needs of the nnrse 

S oTT 1 ^ SCh ° 01 3Ud after gradUati0D - A ™™» Mr- 

Z/f T g T n iS eX3Ct,y the b00k for »*** nurses 
and others have long and vainly sought. ' ' 

Cloth, $1.50 net 

Friedenwald & Ruhrah on Diet T 

lia11 V11 *-*lwl THIRD EDITION 

Galbraith's Personal Hygiene and Physical 
Training for Women 

of 37. pages, illustrated k A " denl v of Medicine. , M . 

Cloth, $2.00 net. 

Galbraith's Four Epochs of Woman's Life 

THE NEW (2d) EDITION 
of^s^ania. A,*3V*££ » "«"-• M 6 ^£« 



McCombs' Diseases of Children for Nurses 

JUST ISSUED— NEW (2d) EDITION 

Dr. McCombs' experience in lecturing to nurses has enabled 
him to emphasize just those points that nurses most need to know. 
National Hospital Record says: "We have needed a good 
book on children's diseases and this volume admirably fills 
the want." The nurse's side has been written by head 
nurses, very valuable being the work of Miss Jennie Manly. 

Diseases of Children for Nurses. By Robert S. McCombs, M. D., 
Instructor of Nurses at the Children's Hospital of Philadelphia. i2mo 
of 470 pages, illustrated. Cloth, $2.00 net 

Wilson's Obstetric Nursing 

In Dr. Wilson's work the entire subject is covered from the 
beginning of pregnancy, its course, signs, labor, its actual 
accomplishment, the puerperium and care of the infant. 
American Journal of Obstetrics says: " Kvery page empasizes 
the nurse's relation to the case." 

A Reference Handbook of Obstetric Nursing. By W. Reynolds 
Wilson, M.D., Visiting Physician to the Philadelphia Lying-in Char- 
ity. 32010 of 355 pages, illustrated. Flexible leather, $1.25 net. 



NEW (6th) EDITION 



American Pocket Dictionary 

The Trained Nurse and Hospital Review says: "We have 
had many occasions to refer to this dictionary, and in every 
instance we have found the desired information." 

American Pocket Medical Dictionary. Edited by W. A. Newman 
Dorland, A. M., M. D., Loyola University, Chicago. Flexible 
leather, gold edges, $1.00 net; with patent thumb index, $1.25 net. 



SECOND 
EDITION 



Lewis' Anatomy and Physiology 

Nurses Joarnal of Pacific Coast says * ' it is not in any sense 
rudimentary, but comprehensive in its treatment of the sub- 
jects." The low price makes this book particularly attractive. 

Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., Lec- 
turer on Anatomy and Physiology for Nurses, Lewis Hospital, Bay 
City, Mich. i2mo of 375 pages, 150 illustrations. Cloth, $1.75 net 



Dorland's Illustrated Dictionary 



NEW (5th) 
EDITION 



The American Illustrated Medical Dictionary. Edited by W. A. N. 
Dorland, M.D. Large octavo of 876 pages, 2g3 illustrations, ng in 
colors. Flexible leather, $4.50 net ; thumb indexed, $5.00 net. 



Paul's Materia Medica 



A Text-Book of Materia Medica for Nurses. By George P. Paul.M.D., 
Samaritan Hospital, Troy, N. Y. 12010 of 240 pages. Cloth, $1.50 net. 



Paul's Fever Nursing 



Nursing in the Acute Infectious Fevers. By GEORGE P. Paul, M.D. 

Cloth, $1.00 net. 



Hoxie's Medicine for Nurses 

Practice of Medicine for Nurses. By George Howard Hoxie, M.D., 
University of Kansas. With a chapter on Technic of Nursing by 
Pearl L. Laptad. i2mo of 284 pages, illustrated. Cloth, $1.50 net. 

Grafstrom's Mechano-therapy ££££ 

Mechano-therapy (Massage and Medical Gymnastics). By Axel V. 
Grafstrom, B.Sc. M.D., i2mo, 200 page-. Cloth, $1.25 net. 

Nancrede's Anatomy 

Essentials of Anatomy. Cha 

ity of Michigan. 12010, 400 ] 

Morrow's Immediate Care of Injured 

Immediate Care of the Injured. By A 
York City Home for Aged and Infirm, 
illustrations. Cloth, $2.50 net. 

Register's Fever Nursing 

A Text Book on Practical Fever Nurs 
M.D., North Carolina Medical Collej 
trated. 

Pyle's Personal Hygiene 



NEW (7th) EDITION 

Essentials of Anatomy. Charles B. G. deNancRede, M.D., Univers- 
ity of Michigan. 12010, 400 pages, 180 illustrations. Cloth, $1.00 net 



Immediate Care of the Injured. By Albert S. Morrow, M.D,, New 
York City Home for Aged and Infirm. Octavo of 340 pages, with 238 
illustrations. Cloth, $2.50 net. 



A Text Book on Practical Fever Nursing. By Edward C. Register, 
M.D., North Carolina Medical College. Octavo of 350 pages, illus- 
trated. Cloth, $2. so net. 



NEW (4th) EDITION 

A Manual of Personal Hygiene. Edited by Walter L. Pyle, M.D. 

Wills Eye Hospital, Philadelphia. i2mo, 472 pages, illus. $1.50 net. 



Morris' Materia Medica 



NEW (7th) EDITION 

Essentials of Materia Medica, Therapeutics, and Prescription Writing. 
By Henry MORRIS, M.D. Revised by W. A. Bastedo, M.D., Colum- 
bia University, N. Y. nmo of 300 pages, illustrated. Cloth, $1.00 net. 



Griffith's Care of the Baby 



JUST ISSUED 
NEW (5th) EDITION 



The Care of the Baby. By J. P. CROZER Griffith, M.D., Univers- 
ity of Pennsylvania. i2mo of 455 pages, illustrated. Cloth, $1.50 net. 



JUN 16 191! 



One copy del. to Cat. Div. 



JUN 



\%. ^ l1 



